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Digitized  by  the  Internet  Archive 

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Open  Knowledge  Commons 


http://www.archive.org/details/surgicalaftertreOOcran 


SURGICAL 
AFTER-TREATMENT 

A  MANUAL  OF 
THE  CONDUCT  OF  SURGICAL  CONVALESCENCE 


BY 

L.  R.  G.  CRANDON,  A.  M.,  M.  D. 

ASSISTANT   IN  SURGERY    AT     HARVARD    MEDICAL    SCHOOL;    ASSISTANT^  VISITING  SURGEON 

TO  THE   BOSTON    CITY    HOSPITAL  ;    CONSULTING    SURGEON, 

FROST    GENERAL    HOSPITAL 


WITH  265  ORIGINAL  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.    B.     SAUNDERS    COMPANY 

1911 


Copyright,  1910,  by  W.  B.  Saunders  Compacy 


Reprinted  January,  1911 


r-. 


VX..\ 


C-v-fi^- 


PRINTED     IN      AM  ERIC  a 

PRESS      OF 

W.      B.     SAUNDERS       COMPANY 

PHI  l_ADEl_PHlM 


TO 

M.   A.    C. 


PREFACE 


These  suggestions  for  After-treatment  of  Surgical  Cases  are  written 
for  two  classes  of  practitioners :  house  surgeons  in  hospitals  and  general 
practitioners  in  communities  which  are  not  surgical  centers. 

Hospitals  develop  traditions  of  treatment;  the  graduating  house 
surgeon  is  an  oracle  to  the  beginning  junior  officer;  the  visiting  surgeon 
leaves  most  of  the  postoperative  detail  to  the  house  surgeon,  and  if  the 
latter  has  good  sense  in  addition  to  his  academic  knowledge,  he  is  able  to 
use  the  traditions  of  treatment  which  he  has  inherited  from  his  prede- 
cessor in  office  wisely,  and  matters  of  after-treatment  in  the  wards  go 
on  serenely.  Traditions  and  customs,  however,  may  be  bad,  and  it 
seems  unnecessary,  if  it  is  avoidable,  that  each  succeeding  house  officer 
should  have  to  learn  all  details  of  after-treatment  empirically  and  at  the 
patient's  expense.  It  must  be  admitted  that  the  danger  of  an  arbitrary 
printed  page  may  be  greater  than  that  of  a  verbal  tradition  of  treatment, 
but  if  these  pages  can  serve  to  show  that  successful  after-treatment,  like 
successful  primary  treatment,  depends  first  on  common  sense,  that  each 
case  should  suggest  its  own  after-treatment  to  some  degree,  that  an 
arbitrary  rule  is  dangerous,  the  book  will  have  served  its  purpose. 

When  the  metropolitan  surgeon  operates  in  the  smaller  towns,  he 
leaves  the  case  after  operation  in  the  hands  of  his  consultant,  who  may 
not  be  a  man  of  recent  hospital  experience.  For  such  a  man  a  manual 
of  elastic  but  detailed  directions  should  be  of  value. 

Every  procedure  herein  advised  has  stood  the  test  of  practice  and 
will  safely  do  for  the  reader  until,  from  his  own  experience,  he  develops 
his  own  methods.  The  fact  that  each  surgeon  eventually  grows  into  a 
technique  peculiar  to  himself,  and  that  many  differing  ways  are  suc- 
cessful, should  make  us  liberal  in  spirit  and  constantly  alert  for  new 
truth.  No  surgical  life  is  so  brief  but  that  it  has  seen  new  methods  ap- 
pear, vaunted  as  perfect,  pursued  for  a  time,  only  to  fade  away. 

Statistics  are  given  little  place,  therefore,  in  this  work.  It  is  little 
comfort  to  a  patient  that  ninety-out  of  a  hundred  with  his  malady  get 
well.  Such  a  statement  contains  no  assurance  that  he  is  not  of  the  ten. 
Furthermore,  we  must  acknowledge  some  truth  in  Christopher  Heath's 
remarks  (Brit.  Med.  Jour.,  1892,  i,  1243):  "Of  course,  we  hear  of  one 
case  that  did  recover,  but  do  not  hear  of  the  ninety  and  nine  cases  that 


8  PREFACE 

did  not.  When  a  man  has  a  case  of  that  kind  which  gets  well,  he  puffs 
it  tremendously,  and  you  always  hear  of  it;  but  those  who  have  unsuc- 
cessful cases  are  content  to  leave  them  alone  and  keep  them  out  of  the 
Journal;  therefore,  you  must  not  believe  too  much  in  statistics.  As 
soon  as  a  gentleman  begins  to  work  up  his  statistics,  his  moral  faculty 
appears  to  become  relaxed." 

Finally,  I  wish  to  quote  from  an  admirable  letter  written  by  Gustavus 
Richard  Brown,  January  2,  1800,  to  Dr.  Craik,  concerning  the  last 
illness  and  death  of  General  Washington: 

"We  were  governed  by  the  best  light  we  had;  we  thought  we  were 
right,  so  we  are  justified. 

"Dr.  Rich  is  a  most  sensible  man.  He  uses  his  common  sense  in- 
stead of  the  books  as  his  guide  in  his  profession,  and  he  is  no  bigot.  He 
says  our  professional  practice  needs  great  reform,  and  that  can  be  brought 
about  only  by  each  individual  becoming  a  practical  reformer  himself. 
He  is  disposed  to  put  up  his  lancet  forever  and  turn  nurse  instead  of 
doctor,  for  he  says  one  good  nurse  is  more  likely  to  assist  nature  in 
making  the  cure  than  ten  doctors  will  by  their  pills  and  lancet."  (Loss- 
ing's  Hist.  Rec,  ii,  501.) 


I  wish  here  to  thank  Dr.  Albert  Ehrenfried,  of  Boston,  for  continuous 
and  enthusiastic  assistance  in  the  preparation  of  this  manual — assistance 
which  has  amounted  to  collaboration. 

Dr.  George  P.  Sanborn,  of  Boston,  a  leading  disciple  of  Sir  Almroth 
E.  Wright  in  America,  has  written  the  chapter  on  Vaccine  Therapy,  a  con- 
tribution I  was  very  fortunate  to  get.  He  also  prepared  the  section  on 
Intubation,  based  on  an  experience  of  three  hundred  cases. 

Dr.  Frank  B.  Granger,  of  Boston,  has  contributed  the  section  on 
Electrotherapeutic  Technique,  to  my  great  satisfaction. 

Such  a  manual  as  this  must  be,  to  a  degree,  a  compilation.  I  have 
used  the  literature  freely,  meaning  in  each  instance  to  give  full  credit  and 
exact  reference. 

Thanks  are  due,  and  are  herewith  gladly  given,  to  Doctors  John 
H.  McCollom,  John  Bapst  Blake,  Frederick  J.  Cotton,  John  H.  Blodgett, 
Nathaniel  R.  Mason,  Allen  G.  Rice,  John  T.  Williams,  Walter  M. 
Boothby,  and  Miss  Mabel  R.  Harris,  for  suggestions,  criticism,  and 
other  material  assistance. 

L.  R.  G.  CRANDON. 

Boston,  Massachusetts, 

366  Commonwealth  Avenue. 


CONTENTS 


PART  I 

CHAPTER  I  PAGE 

Sick-room,  Nurse's  Chart,  Posture 17 

Sick-room 17 

Nurse's  Chart 21 

Posture 23 

CHAPTER  II 

Anesthesia — After  the  Anesthetic:  Nausea,  Vomiting,  Hematemesis,  Rest- 
lessness, Sweating 27 

Anesthesia 27 

After  the  Anesthetic 28 

Nausea  and  Vomiting 32 

Recovery-room 35 

Hematemesis 38 

Restlessness 39 

Sweating 40 

CHAPTER  III 
Thirst,  Its  Significance  and  Relief 41 

CHAPTER  IV 
Pain  and  Sleep 47 

CHAPTER  V 

Pulse,  Temperature,  and  Respiration 52 

Pulse 52 

Temperature 58 

Respiration 63 

CHAPTER  VI 

Postoperative  Hemorrhage:  Primary,  Delayed,  Secondary;  Transfusion 64 

Primary  Hemorrhage 64 

Delayed  Hemorrhage 64 

Secondary  Hemorrhage 67 

Transfusion 70 

CHAPTER  VII 

Shock 83 

Causes 83 

Symptoms 84 

Treatment 84 

Massage  of  the  Heart 92 

CHAPTER  VIII 

Coma:  Diabetic,  Uremic.     Collapse;  Sudden  Death 94 

Diabetic  Coma 94 

Uremic  Coma 95 

Collapse 97 

Sudden  Death 97 

9 


lO  CONTENTS 


CHAPTER  IX 


PAGE 


Thrombophlebitis;  Pulmonary  Embolism;  Pylephlebitis;  Subdiaphragmatic 

Abscess gg 

Thrombophlebitis no 

Pulmonary  Embclism loi 

Heart-clot 105 

Pylephlebitis 106 

Subdiaphragmatic  Abscess 107 

CHAPTER  X 
Artificial  Respiration;  Oxygen;  Electricity 109 

CHAPTER  XI 
Diet  after  Operation 114 

CHAPTER  XII 

Rectal  Feeding ." ,   120 

Formulas  for  Nutrient  Enemas 125 

CHAPTER  XIII 

Gavage  and  Other  Forms  of  Artificial  Feeding 127 

Nasal  Feeding 129 

Subcutaneous  Feeding 130 

Feeding  in  Gastric  Fistula 131 

After  Laryngeal  Operations 131 

CHAPTER  XIV 

Catheterization;  Cystitis;  Catheter  Fever 133 

Catheterization 133 

Cystitis 136 

Catheter  Fever 140 

CHAPTER  XV 

Care  of  the  Bowels:  Cathartics,  Enemas,  Distention,  Fomentations 143 

Cathartics 145 

Enemas 148 

Distention 151 

CHAPTER  XVI 

Acute  Intestinal  Obstruction;  Acute  Gastric  Dilatation 156 

Acute  Intestinal  Obstruction 156 

.    Acute  Gastric  Dilatation 157 

CHAPTER  XVII 
Bursting  of  the  Abdominal  Wound 163 

CHAPTER  XVIII 

Sequels  of  the  Anesthesia:  Conjunctivitis,  etc..  Pneumonia,  Nephritis.  .  . .  164 

Sore  Jaw 164 

Sore  Tongue 164 

Sore  Chest : • 164 

Burns '. 165 

Paralysis 165 

Conjunctivitis 165 

Pneumonia 166 

Nephritis • 169 


CONTENTS  II 

CHAPTER  XIX  PAGE 

Acetonemia;  Acetonuria;  Acidosis;  Acid  Intoxication;  Fatty  Degeneration 

OF  the  Liver 172 

CHAPTER  XX 

Hiccough:  Causes,  and  Treatment lyg 

CHAPTER  XXI 

The  Tongue:  Its  Significance 182 

CHAPTER  XXII 

Bandaging 186 

CHAPTER  XXIII 

Treatment  of  the  Operative  Wound:  Dressing,  Stitches,  Drainage,  and 

Stitch-abscess 209 

Time  for  Dressing 210 

Aseptic  Wounds 210 

Stitches 210 

Drainage 214 

Stitch-abscess 221 

CHAPTER  XXIV 

Treatment  of  Septic  Wounds:  Soaks,  Poultices;  Hyperemia,  Passive  and 

Active 225 

Heat • 226 

Poultices 228 

Bier  Hyperemic  Treatment 230 

CHAPTER  XXV 

Sinuses,  and   Fistula:   Lymphatic   Fistula,  Fecal  Fistula,  and  Artificial 

Anus 240 

Sinuses  and  Fistulae 240 

Lymphatic  Fistula 245 

Fecal  Fistula 246 

Artificial  Anus 248 

CHAPTER  XXVI 

Septicopyemia 250 

CHAPTER  XXVII 

Cutaneous  Rashes:  Ether  Rash,  Septic  Rash,  Erysipelas,  Surgical  Scarla- 
tina, Drug  Poisoning 2i;3 

Ether  Rash 253 

Septic  Rash 253 

Erysipelas 254 

Surgical  Scarlatina 2^5 

Drug  Poisoning 256 

CHAPTER  XXVIII 

Rare  Complications:  Tetanus,  Malignant  Edema,  Parotitis,  Status  Lymphati- 

cus,  Hemophilia 259 

Postoperative  Tetanus 259 

Gas-bacillus  Infection 262 

Parotitis 263 

Status  Lymphaticus 265 

Hemophilia 266 


12  CONTENTS 

CHAPTER  XXIX  page 

Habits  and  Their  Relation  to  Surgical  Conditions:  Alcohol,  Morphin, 

CocAiN,  Tea,  Tobacco,  Snufp 270 

Alcohol 270 

Morphin 271 

Cocain 272 

Tea  and  Coffee 272 

Tobacco  and  Snuff 272 

CHAPTER  XXX 

Postoperative  Psychoses:  Delirium  Tremens,  Insanity,  Menopause 273 

Delirium  Tremens 273 

Postoperative  Insanity 276 

Menopause 278 

CHAPTER  XXXI 
General  Treatment  in  Convalescence 280 

CHAPTER  XXXII 
Bed-sores:  Causes,  Prevention,  and  Treatment 283 

CHAPTER  XXXIII 
Foreign  Bodies  Left  in  the  Abdominal  Cavity 286 

CHAPTER  XXXIV 

Postoperative  Hernia;  Adhesions 291 

Postoperative  Hernia 291 

Adhesions 294 

CHAPTER  XXXV 
Abdominal  Swathes:  Their  Use  and  Abuse 301 

CHAPTER  XXXVI 
Aetipicial  Limbs;  Postoperative  Flat-foot 307 

Artificial  Limbs 307 

Postoperative  Flat-foot 3^2 

CHAPTER  XXXVII 

Friction,  Massage,  Percussion,  Remedial  Movements 316 

Friction 3^7 

Massage " 3^° 

Percussion 3^7 

Remedial  Movements 3^8 

CHAPTER  XXXVIII 
Electrotherapy;  X-ray  Therapy;  Radium 335 

Indications 33^ 

Electrotherapeutic  Technique 34^ 

CHAPTER  XXXIX 

Preparation  of  the  Patient .' • 348 

Catharsis 349 

Diet 350 

Field  of  Operation 35^ 

Preparation  of  Special  Areas 355 


CONTENTS 


PART  II 


CHAPTER  XL 


13 


PAGE 


Operations  on  the  Head  and  Face ^58 

Scalp  Wounds ^rg 

Trephining  and  Brain  Operations 258 

Removal  of  the  Gasserian  Ganglion  and  Other  Nerve  Resections 360 

Excision  of  the  Upper  and  Lower  Jaw 360 

Tumors  of  the  Parotid 361 

Enucleation  of  the  Eye 362 

Other  Plastic  Operations  on  the  Face 363 

CHAPTER  XLI 

Operations  on  the  Mouth,  Nose,  and  Pharynx 364 

Hare-lip 364 

Cleft -palate 365 

Excision  of  the  Tongue,  Partial  or  Complete 367 

Ranula 368 

Alveolar  Abscess 369 

Paraffin  Prosthesis  for  Deformity  of  the  Nose  and  Other  Parts 370 

Nasal  Polypi  and  Spurs 371 

Antrum  of  Highmore 372 


Frontal  Sinus. 
Removal  of  Adenoids. 
Removal  of  Tonsils. .  . 


373 
373 

375 


Tumors  of  the  Tonsil 376 

Peritonsillar  Abscess 377 

Retropharyngeal  Abscess 377 

CHAPTER  XLII 

Operations  on  the  Neck 378 

Tracheotomy 378 

Laryngotomy 381 

Intubation 382 

Esophagotomy 390 

Partial  Thyroidectomy 390 

Excision  of  Lymph-nodes  of  the  Neck 396 

Incision  and  Excision  of  Carbuncle  of  the  Neck 397 

Branchial  Cysts  and  Sinus 398 

Mastoiditis 398 

CHAPTER  XLIII 

Operations  on  the  Thorax ; 401 

Amputation  of  the  Breast ,  .  401 

Excision  of  Benign  Tumors  of  the  Breast 402 

Abscess  of  the  Breast 403 

Empyema 404 

Abscess  of  the  Lung 408 

Thoracoplasty  (Estlander's  Operation;  Schede's  Operation) 409 

Operations  on  the  Pericardium 409 

Gun-shot  and  Stab-wounds  of  the  Chest 409 

CHAPTER  XLIV 

Operations  on  the  Abdomen.  . .  ,■ 411 

Gastro-enterostomy 411 

Gastrostomj' 413 

Gastrectomy 41^ 

Pyloroplasty 416 

Gastroplication 417 


14  CONTEXTS 

PAGE 

Operations  ox  the  Abdomen — Pj-lorectomy 418 

Perforated  Gastric  Ulcer 418 

Perforated  Duodenal  Ulcer 421 

Colostomy 421 

Jejunostomy 427 

Intestinal  End-to-end  Anastomosis,  or  Circular  Enterorrhaphy 427 

Abscess  of  Liver 428 

Hydatid  Cyst  of  Liver 429 

Gall-bladder  and  Biliary  Passages 430 

Cholecystotomy 431 

Cholecystenterostomy 433 

Cholecystgastrostomy 434 

Choledochotomy 434 

Choledochostomy 43^ 

Choledochenterostomy,  Chcledochectomy 435 

Choledochoduodenostomy 435 

Duodenocholedochotomy 435 

Hepaticodochotomy 435 

Hepaticodochostomy.  . .  .' 436 

Hepaticodocholithotripsy 436 

Gun-shot  and  Other  Injuries  of  the  Abdomen 437 

CHAPTER  XLV 

Operations  on  the  Abdomen  (Contixtjed) 439 

The  Radical  Cure  of  Hernia 43Q 

Large  Incarcerated  Hernia 443 

Strangulated  Hernia  (Inguinal  or  Femoral) 445 

Operations  on  the  Pancreas 447 

Drainage  of  Pancreatic  C3st 448 

Splenectomy 450 

Appendicostomy 451 

Appendicitis  and  Its  Complications 454 

General  Peritonitis 468 


CHAPTER  XLAT 

OPER.A.TIONS  on  the  Vagina,  Uterus,  and  Adnexa 471 

Incomplete  Perineorrhaphy  and  the  Repair  of  Rectocele 471 

Complete  Perineorrhaphy 473 

Repair  of  Cystocele 474 

Vesicovaginal  Fistula 475 

Rectovaginal  Fistula 476 

Excision  of  the  Vulva 476 

Excision  of  Urethral  Caruncle 477 

Vulvovaginal  Abscess 477 

Cyst  of  BarthoHn's  Gland 478 

Vaginal  Section  (Cclpotomy)  for  Drainage  of  Pehic  Abscess 478 

Vaginal  Section  for  Removal  of  the  Appendages 480 

Vaginal  Hysterectomy 481 

Operations  on  the  Cervix  Uteri 483 

Curettage  for  Aborlicn  and  Miscarriage 484 

Curettage  for  Endometritis  or  Anteflexion 489 

Symphysiotomy 490 

Pubiotomy 492 

Operations  for  Retroversion  and  Lesser  Operations  on  ihe  Appendages 493 

Ovariotomy 493 

Salpingo-oophorectcmy  for  Salpingitis  and  Ovarian  Abscess 495 

Tuberculous  Salpingitis 498 

Abdominal  Hysterectomy ' 499 

Celiotomy  for  Extra-uterine  Pregnancy 502 

Cesarean  Section 503 

Other  Operations 506 

Eclampsia 507 


CONTENTS  15 

CHAPTER  XLVII  page 

Operations  on  the  Penis,  Scrotum,  Urethra,  and  Prostate 510 

Circumcision 514 

Meatotomy 515 

Hypospadias 516 

Epispadias 516 

Hydrocele 516 

Varicocele 517 

Undescended  Testis ; 518 

Castration 518 

Internal  Urethrotomy 518 

External  Urethrotomy 519 

Ruptured  Urethra 528 

Perineal  Prostatectomy 528 

Suprapubic  Prostatectomy 530 

Prostatotomy  for  Pro'static  Abscess 532 

CHAPTER  XLVni 
Operations  on  the  Kidney,  Ureter,  and  Bladder 533 

Nephrotomy 533 

Nephrectomy 539 

Nephrorrhaphy 541 

Operations  upon  the  Ureter 543 

Suprapubic  Cystotomy 543 

Lateral  Cystotomy 545 

Median  Perineal  Lithotomy 545 

Vaginal  Cystostomy 545 

Exstrophy  of  the  Bladder 546 

CHAPTER  XLIX 

Operations  on  Anus  and  Rectum 548 

Fissure  in  Ano 548 

Fistula  in  Ano 548 

Imperforate  Anus;  Imperforate  Rectum 549 

Ischiorectal  Abscess 549 

Hemorrhoids , 550 

Prolapse  of  Rectum 553 

Kraske's  Operation  for  Cancer  of  the  Rectum 553 

Weir's  Combined  Operation  for  Cancer  of  the  Rectum 556 

Vaginal  Proctectomy 557 

CHAPTER  L 

Operations  on  the  Extremities 558 

Amputations 558 

Ligation  of  the  Innominate  Artery , 560 

Ligation  of  the  Carotid  Artery 561 

Ligation  of  the  Subclavian  Artery 561 

Ligation  of  the  E.xternal  Iliac  or  Femoral  Artery 02 

Arterial  Suture 562 

Matas'  Operation  for  Aneurysm. 563 

Varicose  Veins  of  Lower  Extremity 564 

Suture  of  Tendon  and  Muscle 565 

Tendon  Transplantation 566 

Nerve  Suture 566  . 

Suture  of  the  Brachial  Plexus 567 

Nerve  Anastomosis 567 

Psoas  Abscess 569 

Inguinal  Bubo  (Abscess  of  the  Groin) 570 

Paronychia  and  Perionychia. 570 

Ingrowing  Toe-nail 570 

Palmar  Ganglion;  Tuberculous  Tenosynovitis 570 

Dupuytren's  Contraction 571 

Skin-grafts 572 


l6  CONTENTS 


CHAPTER  LI 


PAGE 


Operations  on  Bones  and  Joints 574 

Excision  of  Elbow ^74 

Excision  of  Shoulder-joint ^74 

Excision  of  Wrist ^7^ 

Excision  of  Hip 575 

Excision  of  Knee 575 

Open  (or  "  Compound")  Fractures 576 

Operative  Fixation  of  Fractures 585 

Operations  on  the  Knee:  Dislocated  Cartilage,  Synovial  Fringe 588 

Operation  for  Recurrent  Dislocation  of  the  Shoulder 589 

Operation  for  Purulent  Arthritis 590 

Osteomyelitis 590 

Operations  for  Bow-legs,  Knock-knees,  and  Coxa  Vara 592 

Club-foot  (Congenital  Equinovarus) 593 

Hallux  Valgus 597 

Operation  for  Spina  Bifida 597 

Laminectomy 599 

CHAPTER  LII 

Therapeutic  Immunization  and  Vaccine  Therapy 601 

Principles  of  Immunization 601 

Preparation  of  Bacterial  Vaccine 659 

Laboratory  Technic , 660 

The  TubercuUns 673 

The  Determination  of  the  Opsonic  Index 675 

Agglutination  Test  (Wright's  Method) 682 

Note  Concerning  the  Sterilization  of  Vaccines 685 

Clinical  Practice 686 

Acute  Fulminating  Infections 686 

Generalized  Infections 693 

Infectious  Arthritis 700 

Localized  Staphylococcic  Infections 712 

Locahzed  Tuberculosis 731 

LupUs 749 

.   Genito-urinary  Tuberculosis 75  r 

Tuberculin  Treatment 760 

New  Methods  of  KilUng  Bacteria  for  Vaccines — The  Use  of  Living  Vac- 
cines   763 

Dosage  Table 768 

CHAPTER  LIII 
CoLEY  Serum  eor  Malignant  Tumors 771 

APPENDIX 
Some  Invalid  and  Convalescent  Food  Recipes 774 


Index  of  Authors 781 

Index 789 


SURGICAL  AFTER-TREATMENT 

PART  I 


CHAPTER  I 
SICK  ROOM,  NURSE'S  CHART,  POSTURE 

As  a  rule,  the  end  of  the  operation  marks  the  beginning  of  the  sur- 
geon's care  and  anxiety.  In  operating,  the  surgeon  consumes  from 
fifteen  minutes  to  one  hour — rarely  longer — in  performing  a  piece  of 
surgical  technique  with  which  he  presumably  feels  quite  at  home.  When 
the  patient  leaves  the  table,  however,  he  goes  over  into  strange  hands 
for  an  indefinite  period  of  convalescence,  with  all  its  discomforts  and  all 
the  possibility  for  mishap.  The  surgeon  must  now  depend,  in  a  large 
measure,  upon  others  to  carry  out  his  plans  for  after-treatment  and  to 
keep  him  informed  of  the  changes  that  may  develop  from  hour  to  hour 
and  the  emergencies  that  may  arise.  For  the  time  being,  he  must  relegate 
a  portion  of  his  authority  and  responsibility  to  the  person  in  charge — 
the  nurse  in  a  private  family,  or  the  house  officer  in  a  hospital.  Skilful 
after-treatment  has  pulled  through  many  a  forlorn  hope,  while  neglect 
in  the  after-care  will  negative  the  most  skilful  effort  of  the  best  surgeon. 
Success  in  after-treatment  means  the  successful  mastery  of  a  mass  of 
details. 

SICK  ROOM 

The  room  in  which  the  patient  is  to  pass  his  convalescence  should 
be  large,  airy,  well  ventilated,  and  capable  of  being,  adequately  heated. 
If  in  a  private  house,  it  should  be  situated  apart  from  the  living  rooms 
and  cooking,  and  near  to  a  bath-room.  The  walls  should  be  painted 
in  plain  colors,  without  figures.  The  floor  should  be  of  polished  wood, 
linoleum,  or  concrete,  and  without  carpets. 

The  bed  should  be  light,  easily  movable,  w^ith  low  head-  and  foot- 
pieces,  best  made  of  enamelled  iron,  so  that  it  may  be  readily  and  thor- 
oughly cleansed.     It  should  be  narrow,  and  stand  so  high  above  the 

2  17 


i8 


SICK   ROOM,   nurse's   CHART,    POSTURE 


floor  that  the  patient  can  be  easily  dressed  and  attended.  It  should  be 
so  placed  that  the  niirse  can  readily  get  around  all  sides  of  it,  and  so 
situated  that  the  patient  does  not  have  to  look  directly  at  a  window  or 
have  the  sun  strike  his  face.  It  is  weU  to  have  blocks,  which  may  be 
placed  under  the  head  or  foot  casters  of  the  bed,  and  to  have  boards  to 
be  placed  across  the  middle  of  the  frame  to  support  the  spring  if  it  sags 
and  gives  the  patient  a  backache. 

Two  small  and  rather  hard  feather  pillows  will  suffice.  One  may 
be  encased  in  rubber  for  use  if  the  patient  vomits.  Sometimes  several 
pillows  of  different  sizes  are  handy  to  place  under  the  small  of  the  back 
or  under  the  knees  of  the  patient,  as  after  an  inguinal  hernia  operation, 
or  to  place  against  the  foot  of  the  bed  for  the  patient  to  brace  his  feet 
against,  in  case  the  head  of  the  bed  is  elevated. 


Fig.  I. — Changing  the  Bed. 
A  blanket  is  thrown  over  the  whole  bed,  and  the  bed-coverings  are  pulled  out  from  beneath. 


A  small  enamel  or  wooden  table  may  be  useful,  placed  at  the  right 
side  at  the  head  of  the  bed.  Otherwise,  save  for  a  chair  or  two,  there 
should  be  no  furnishings  in  the  room.  Ornaments,  pictures,  hangings, 
and  bric-a-brac  are  out  of  place.  There  should  be  a  convenient  hook 
or  nail  to  be  used  in  hanging  up  a  fountain  syringe. 

The  bed  should  be  provided  with  a  firm,  level,  horsehair  mattress. 
A  water-bed  may  be  necessary  in  the  enfeebled  or  emaciated  to  prevent 
bed-sores.  The  water-bed  sometimes  imparts  a  sensation  akin  to  sea- 
sickness. Over  the  mattress  comes  the  sheet;  a  narrow  rubber  "draw- 
sheet"  is  placed  across  the  middle  of  the  bed.  The  full-sized  sheet, 
once  folded  upon  itself,  is  also  placed  across  the  bed  to  cover  the  rubber 


SICK   ROOM 


19 


sheet.     This  is  of  great  convenience,  because  it  can  be  so  readily  changed 
when  soiled  by  discharges,  dressings,  irrigations,  or  the  bed-pan. 


Fig.  2. — Changing  the  Bed. 
Patient  wrapped  in  blanket  is  turned  to  left  side.     All  the  under  bed-clothes  on  right  side  are  rolled  up  toward 

the  middle  of  the  bed. 

In  changing  the  draw-sheet  a  nurse  stands  on  each  side  of  the  bed. 
One  nurse  gently  turns  the  patient  toward  the  side  nearest  her,  while 


Fig.  3. — Changing  the  Beu. 
Clean  undersheet  and  rubber  draw-sheet  are  laid  on  right  side  of  bed. 

the  Other  rolls  up  the  soiled  sheet,  wipes  off  the  rubber  draw-sheet,  and 
lays  on  the  clean  sheet,  which  has  been  folded  and  rolled  up,  and  tucks 
her  end  in  under  the  mattress.     Then  the  patient  is  allowed  to  turn  on 


20 


SICK   ROOM,    NURSE  S   CHART,    POSTURE 


his  back  and  is  gently  rolled  on  the  other  side,  while  the  other  nurse  pulls 
out  the  soiled  sheet,  wipes  off  the  rubber  sheet  on  her  side,  unrolls  the 


p^'ST'^ 


-JPS*" ^ — KfT" 


Fig.  4. — Changing  the  Bed. 
Clean  draw-sheet  similarly  applied. 

clean  draw-sheet  from  under  the  patient,  and  tucks  her  end  in,  taking 
care  that  it. is  tightly  stretched  and  smooth.     This  procedure  may  be 


p-T«^' 


Fig.  5. — Changing  the  Bed. 

Patient  rolled  over  on  his  right  side.     Soiled  under  bed-clothes  are  removed  from  left  side  of  bed,  and  rolled  up 

portion  of  clean  ones  pulled  through  and  tucked  in. 


easily  carried  through  by  a  single  nurse,  provided  the  patient  can  be 
turned  without  danger. 


nurse's  chart 


21 


The  under  sheet  may  be  changed  in  the  same  way.  The  under 
sheet  should  be  changed  every  morning  and  the  draw-sheet  as  often  as 
necessary.  The  bed  should  be  kept  free  from  crumbs  and  food  par- 
ticles, w^hich  will  set  up  an  irritation  or  even  lead  to  bed-sore. 

Over  the  patient  all  that  is  necessary  is  a  sheet,  a  blanket,  and  a 
coverlet;  extra  blankets  may  be  added  when  necessary. 

The  nurse  should  see  that  she  has  at  hand  a  4-quart  fountain  syringe 
and  connections,  a  rectal  tube  and  glass  female  catheter,  a  hard-rubber 
oil  enema  syringe,  bed-pan,  towels,  toilet-paper,  basins,  hypodermic 
syringe  with  strychnin,  morphin,  and  atropin,  feeding-glass,  feeding- 


FiG.  6. — Changing  the  Bed. 
Clean  top  bed-clothes  applied,  temporary  blanket  pulled  out,  counterpane  tucked  in. 

tube,  thermometers,  and  temperature  charts.  In  private  practice  she 
can  depend  upon  the  surgeon  to  supply  or  order  the  other  instruments 
and  drugs  necessary. 

NURSE'S  CHART 

A  surgeon  at  his  visits  will  rely  largely  upon  the  nurse's  chart.  This 
should  be  accurate  and  explicit.  It  should  record  the  temperature,  taken 
twice  daily  (10  a.  m.  and  4  p.  m.),  or  every  four  hours,  as  the  case  de- 
mands, and  at  the  same  time  the  pulse,  and  the  respiration  if  the  surgeon 
wants  it.  The  frequency  and  nature  of  bowel  movements  should  be  stated, 
as  well  as  the  occurrence  and  the  quantity  of  urination.  For  the  first  few 
days  after  operation,  especially  in  stomach  and  other  abdominal  cases, 
it  is  well  to  keep  a  detailed  diet-chart,  recording  the  occurrence  of  vomit- 
ing and  the  stimulation,  nourishment,  and  retention  of  enemas,  sleep, 
etc.     It  is  valuable  also  for  future  record  to  enter  on  the  temperature 


22 


SICK    ROOM,    NURSE  S    CHART,    POSTURE 


Residence. 
Birthplace 


_White  or  Colored 


Date  of  Adm., 


Patient's  Physician. 
Address 


Transfer — See  _ 

Re-E  nthy See, 

Service  of.  Dr._ 


Diagnosis 


Complications  _ 


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URINE. 


COLOR.      REACTION      SP.  GR.      »lBUtlEN      SUGAR, 


SEDIMENT. 


BLOOD. 


CORPUSCLE  COUNTS. 


CORPUSCLE  COUNTS. 


Fig.  7. — Bedstde  Chart  Used  at  the  Massachusetts  General  Hospital  (reduced). 
With  the  exception  of  "Diagnosis"  and  "  Complications,"  which  are  filled  out  only  after  discharge,  this  chart 
contains  no  data  undesirable  for  the  patient  and  his  friends  to  read. 


POSTURE 


23 


chart  the  date  of  operation,  wicks  out,  stitches  out,  the  date  of  sitting  up, 
and  final  discharge.  The  nurse  is  expected  to  be  fully  informed  as  to 
the  pulse  and  temperature,  state  of  the  bowels  and  bladder,  distention, 
vomiting,  pain,  delirium,  sleep,  amount  of  discharge  or  hemorrhage 
if  it  soaks  through  the  dressing,  and  the  occurrence  of  menstruation  or 
vaginal  discharge.  A  nurse  of  experience  can  be  of  help  in  other  ways, 
but  these  things  she  must  know.  Moreover,  she  must  have  sufficient 
judgment  to  be  able  to  decide  whether  to  summon  the  surgeon  and  when 
to  do  so.  Upon  her  devolves  the  responsibility  of  informing  the  surgeon 
of  any  change  or  emergency,  otherwise  it  is  a  matter  of  waiting  upon  the 
patient  and  of  following  explicitly  the  orders  of  the  surgeon  in  charge. 

POSTURE 

The  patient  should  lie  in  bed  in  a  position  of  greatest  ease  and  com- 
fort, provided  this  position  is  not  harmful.  Comfort  and  sleep  are  im- 
portant after  a  serious  operation,  and  anything  which  will  tend  to  induce 


Fig.  8. — Dorsal  Posture. 
Pillow  under  knees  to  relax  abdominal  muscles. 


them — avoiding  opiates — is  diligently  sought  after  and  practised.  It 
has  been  generally  held  that  the  only  proper  posture  for  a  patient  after 
an  operation  of  any  severity  is  the  supine,  with  the  patient  flat  on  his 
back,  and  sometimes,  in  spite  ol  increasing  discomfort,  he  will  not  be 
allowed  to  turn  for  some  days.  The  cases  where  this  rule  need  be  en- 
forced are  few,  and  ordinarily,  in  celiotomies  which  have  been  sewed  up 
tight  and  wear  a  firm  swathe,  there  is  no  reason  why  a  position  of  greater 
comfort  may  not  be  allowed.     In  the  supine  posture  backache  is  frequent, 


24 


SICK   ROOM,   NURSE'S   CHART,    POSTURE 


though  this  may  be  relieved  by  flexing  the  knees  at  45  degrees  on  pillows, 
or  by  placing  a  small  pillow  under  the  hollow  of  the  back  (Fig.  8). 
Few  persons  sleep  on  their  backs,  and  turning  the  patient  gently  on  his 
side  in  the  natural  resting  position,  supporting  his  back  with  a  pillow, 
may  often  induce  sleep. 

Many  women  are  unable  to  empty  the  bladder  lying  upon  the 
back,  and  residual  urine  collects  and  may  develop  into  a  troublesome 
cystitis,  which  could  have  been  obviated  by  turning  the  patient  on  her 
side  to  micturate.  Some  patients  appreciate  being  turned  face  down- 
ward in  bed,  and  drainage  from  a  wound  may  sometimes  be  assisted  by 
this  position.  It  is  frequently  advisable  so  to  prop  up  the  upper  half  of 
the  mattress  that  the  patient  is  in  a  semireclining  posture — for  instance, 


Fig.  9. — Right  Semiprone  Posture. 


in  elderly  persons,  in  cases  of  cardiac  asthma,  bronchitis,  hypostatic 
pneumonia,  and  after  thoracic  and  gastric  operations. 

Royal  Hamilton  Fowler^  gives  an  analysis  of  69  cases  of  diffuse 
septic  peritonitis  operated  upon  in  St.  Luke's  Hospital  in  ten  years. 
He  refers  to  the  article  by  George  Ryerson  Fowler-  on  the  advantages 
of  the  elevated  head  and  trunk  position.  He  concludes  as  follows: 
"  Early  institution  of  postural  drainage  is  of  great  aid  in  preventing  septic 
material  from  reaching  the  diaphragmatic  peritoneum.  The  trunk 
should  be  elevated  during  lavage  of  peritoneum  on  the  table.  The 
manner  of  instituting  postural  drainage  matters  but  little,  provided  that 
the  pelvis  is  sufficiently  low  for  gravitation  to  take  place  and  the  patient 

^  Ann.  Surg.,  1908,  xlviii,  828. 
2  Med.  Rec,  1900,  Iviii,  617. 


FOWLER   POSITION  '  25 

is  comfortable.  A  wooden  frame  may  be  used  with  a  folded  pillow 
between  the  knees  to  prevent  the  patient  from  slipping." 

Many  devices  have  been  described  for  maintaining  a  position  upright 
in  bed.  A  pillow  under  the  knees  is  ineffectual  because  it  is  too  yielding. 
J.  F.  Baldwin^  advises  the  use  of  an  ordinary  rocking-chair.  J.  E. 
Allaben^  describes  a  back  rest  on  the  principle  of  a  double-inclined 
plane.  D.  T.  Gilliam^  advocates  the  use  of  a  steamer  chair.  S.  McGuire* 
elevates  the  head  of  the  bed  and  uses  an  adjustable  seat  to  keep  the 
patient  from  slipping  downward. 

W.  D.  Gatch^  describes  an  apparatus  consisting  of  an  oblong  frame  of 
stout  boards,  to  the  upper  surface  of  which  are  hinged  three  movable  flaps, 
which  can  be  arranged  so  as  to  give  a  sitting  posture.  It  is  of  advantage 
— (i)  to  drain  the  peritoneal  cavity;  (2)  to  lessen  the  danger  of  pulmon- 
ary complications;  (3)  to  permit  of  continuous  irrigation;  (4)  to  permit 
comfort  and  general  well-being  in  the  patient.  The  Fowler  position, 
to  be  at  all  effective,  must  be  maintained  all  the  time. 

H.  T.  Buxton^  has  shown  that  there  is  an  almost  instantaneous  rush 
of  bacteria  into  the  lymphatics  of  the  diaphragm  whenever  infectious 
material  comes  in  contact  with  it. 

R.  C.  Coffey,''  by  means  of  an  ingenious  cast  of  the  peritoneal  cavity, 
has  shown  that  it  is  necessary  to  elevate  a  person's  body  as  high  as  45  to 
50  degrees  to  insure  drainage  of  the  lumbar  depressions  of  the  abdomen. 
The  sitting  posture  is  of  distinct  importance  in  preventing  postoperative 
pulmonary  complications,  especially  in  fat  patients,  after  celiotomies 
for  conditions  of  the  upper  abdomen,  such  as  gall-stone  disease,  gastric 
troubles, 'or  umbilical  hernia.  It  is  a  good  practice  in  patients  who 
are  old  or  feeble,  or  who  have  pulmonary  emphysema  or  bronchitis,  to 
set  them  up  as  soon  as  they  have  recovered  from  the  anesthesia.  Hy- 
postatic congestion  of  the  bases  of  the  lungs  is  not  then  likely  to  occur, 
and  the  liability  of  pneumonia  is  lessened.  If  the  patient  is  held  upright 
without  any  effort  on  his  part,  there  is  no  increased  strain  on  the  abdom- 
inal wound.'  In  distention  this  position  is  advantageous,  in  the  first 
place,  because  the  diaphragm  and  abdominal  muscles  compress  the 
viscera  more  powerfully,  and,  in  the  second  place,  because  in  this  posi- 
tion the  action  of  the  heart  is  less  impeded  by  upward  pressure  of  the 

^  Jour.  Am.  Med.  Assoc,  1907,  xlix,  1043. 

'  Ibid.,  554. 

^  Ibid.,  1908,  li,  1 133. 

*  Ibid.,  1,  1019. 

^  Ann.  Surg.,  1909,  xlix,  410. 

^Jour.  Med.  Research,  1907,  17,   25,  251. 

'jour.  Am.  Med.  Assoc,  1907,  xlviii,  937. 


26  SICK    ROOM,    nurse's    CHART,    POSTURE 

distended  intestines.  Sitting  up  a  distended  patient  always  causes 
an  impro^'ement  in  the  pulse.  As  this  position  takes  the  pressure  o£f 
the  bony  prominences  of  the  back,  patients  are  in  less  danger  of  bed-sores. 
When  sitting  up,  they  can  breathe  better,  they  take  food  and  liquids 
better,  the  vasomotor  tone  of  the  arteries  is  better  preserved,  and  the 
patients  are  not  so  liable  to  dizziness  and  swelling  of  the  feet  when  they 
finally  walk. 

An  efficient  way  to  maintain  Fowler's  position  is  shown  m  Figs.  151, 
152,  and  153,  pages  469  and  470. 


CHAPTER    II 

ANESTHESIA— AFTER  THE  ANESTHETIC:  NAUSEA,  VOM- 
ITING, HEMATEMESIS,  RESTLESSNESS,  SWEATING 

ANESTHESIA 

"Taking  ether"  is  practically  all  the  patient  knows  of  the  so-called 
horrors  of  the  operating-room.  It  is  that  that  he  dreads.  His  last 
words  are,  "Don't  give  it  to  me  too  fast,  don't  smother  me."  This 
part  of  his  experience  should  be  made  as  pleasant  as  possible;  therefore: 

If  an  expert  anesthetist  can  be  obtained,  this  should  be  done.  I 
believe  a  trained  nurse  who  specializes  in  this  field  is  more  satisfac- 
tory than  most  male  anesthetists,'  and  is  distinctly  safer  and  better  than 
the  average  doctor.  As  has  been  said  elsewhere,^  a  perfect  solution  of 
the  problem  of  giving  anesthetics  would  be  a  medical  man  of  high  grade 
of  intelligence,  with  a  well-grounded  medical  and  surgical  education, 
and  especial  education  in  anesthetics,  supplemented  by  a  natural  inclina- 
tion in  this  direction  as  against  any  other.  Are  the  attractions  of  anes- 
thesia sufficient  to  overcome  the  disadvantage  of  the  scientific  narrow- 
ness and  lack  of  opportunity  for  distinction  and  income  to  hold  a  sufficient 
number  of  men  of  this  type,  or  even  of  great  worth,  in  this  field  ?  The 
answer  seems  apparent.  To  the  nurse,  anesthesia  would  prove  a  stepping- 
stone  to  something  better  than  she  had  originally  chosen,  a  higher 
and  more  dignified  position,  and  appeal  in  its  own  way  to  her  ambition 
and  pride,  just  as  does  the  superintendency  of  a  training  school. 
With  the  nurse  anesthetist  is  eliminated  the  inattention  to  the  anesthetic, 
with  its  attendant  annoyances  and  dangers,  there  being  no  desire  for, 
or  chance  of,  an  assistantship  or  future  chiefship. 

An  element  in  humane  and  successful  anesthesia,  where  time  and 
other  conditions  permit,  is  for  the  personal  physician,  if  he  be  at  all 
competent,  or  the  surgeon  himself,  to  start  the  anesthesia.  By  this 
means  no  new  individual  is  introduced  to  the  patient  at  the  last  moment, 
with  a  possible  unpleasant  psychic  effect. 

Nitrous  oxid  gas,  anesthol,  ethyl  chlorid,  and  chloroform  are  all 
less  unpleasant  to  most  patients  for  beginning  anesthesia  than  ether. 
Any  one  of  these  agents  may  be  given  if  there  are  no  contra-indications 

^  J.  M.  Baldy,  Boston  Medical  and  Surgical  Journal,  1909,  clxi,  262. 

27 


28  ANESTHESIA — AFTER    THE   ANESTHETIC 

and  if  the  anesthetist  is  skilled  in  their  administration.  Most  impor- 
tant, first  of  all,  is  that  the  anesthetist  should,  by  preliminary  conversa- 
tion with  patient,  by  air  of  self-confidence,  deliberation  with  no  sug- 
gestion of  hurry,  by  constant  spoken  reassurance  as  the  anesthesia 
proceeds,  gain  and  keep  the  entire  confidence  of  the  patient.  If  at  first 
the  patient  asks  for  a  little  more  air,  he  should  have  it.  Unless  the 
patient  is  likely  to  harm  himself  by  his  struggling,  no  one  should  touch 
any  part  of  the  patient  as  he  goes  under.  In  the  midst  of  the  weird 
dreams  of  ether  intoxication  the  mere  restraining  hand  of  a  bystander 
on  the  patient  may  convert  a  fantasy  into  a  wild  delirium,  a  quiet  patient 
into  a  temporary  maniac.  Successful  etherizing  is  half  hypnotic  in  its 
method. 

In  the  hands  of  the  slightly  skilled  or  the  average  anesthetist,  as 
well  as  the  expert,  I  firmly  believe  that  ether  given  by  the  drop  method 
is  the  safest  and  best  method.  Twelve  to  twenty  layers  of  gauze,  cut 
rectangular  in  shape,  7  by  9  inches,  are  laid  over  nose  and  mouth  and 
tucked  under  chin.  The  patient  gets  used  to  breathing  through  the 
gauze,  and  then,  so  slowly  that  he  may  get  used  to  the  smell,  ether  is 
played  over  nose  and  mouth-area  of  gauze  from  a  single  pin-puncture 
in  the  top  of  a  250-gm.  tin  ether  can.  The  patient  thus  gets  constantly 
ether-laden  air,  which  is  at  the  same  time  always  fresh. 

AFTER  THE  ANESTHETIC 

Immediately  after  the  operation  the  patient  is  wiped  dry,  the  dressing 
or  bandage  is  adjusted,  wet  clothes  changed  for  dry,  and  he  is  wrapped 
in  blankets  and  transferred  to  a  warm  bed,  to  be  carefully  watched 
during  his  recovery  from  the  anesthetic.  In  hospitals  there  is  usually 
set  apart  a  special  room  called  a  recovery  room.  This  should  be  high- 
posted  and  airy,  maintained  at  a  constant  temperature  of  about  70°  F. 
It  should  be  quiet,  with  a  subdued  light,  and  so  isolated  from  the  general 
wards  that  any  disturbance  or  loud  retching  may  not  upset  other 
patients  in  a  critical  condition.  The  room  should  be  barely  furnished, 
the  walls  painted  in  a  plain  color,  and  windows  should  be  barred.  In  a 
private  house  these  conditions  should  be  approximated  as  closely  as 
may  be. 

During  the  recovery  the  patient  should  have  the  undivided  atten- 
tion of  the  nurse  detailed  for  the  purpose;  if  the  patient  is  a  man,  it 
may  be  well  to  have  a  male  nurse  in  attendance  for  the  time  being. 
Vigilance  is  necessary,  not  only  to  prevent  the  unconscious  patient  from 
swallowing  his  tongue  or  choking  in  mucus  or  vomitus,  but  also  from 
injuring  himself  in  delirium,  or  from  removing  or  displacing  his  dress- 


AFTER    THE    ANESTHETIC 


29 


ing.  Rarely  there  may  be  necessity  for  restraining  a  patient  by  means  of 
a  folded  sheet  passed  across  the  body  and  made  fast  to  the  bed-frame 
on  either  side  (Fig.  10),  as,  for  instance,  when  a  delirious,  muscular 
man  is  in  the  care  of  a  little  nurse  who  is  alone.  But  usually,  with  the 
patient  in  a  semiconscious  state,  restraint  of  any  kind  has  a  tendency 
to  cause  him  to  struggle  and  to  increase  the  violence  of  the  delirium. 
It  is  only  rarely  that  delirium  goes  farther  than  random  or  irresponsible 
talk  or  an  attempt  to  sit  up,  and  it  lasts,  as  a  rule,  not  longer  than  ten 
minutes,  so  that  a  competent  attendant  will  not  often  find  use  for  restraint. 
Extra  heaters  and  hot-water  bottles,  well  covered  beyond  the  possibility 


Fig.  io. — Application  of  Restraint. 

Feet  tied  to  foot  of  bed  by  sheet  in  a  clove-hitch;  wrists  tied  to  side  of  bed  by  gauze  bandage  over  a  towel; 
chest  held  to  bed  by  a  folded  sheet  tucked  tightly  around  side-irons. 


of  burning  the  patient,  should  be  at  hand  to  distribute  about  the  patient 
as  necessary. 

Recovery  from  anesthesia  occurs,  roughly  speaking,  with  a  rapidity 
in  inverse  proportion  to  the  length  of  narcosis  and  the  amount  of  anes- 
thetic employed.  Other  facts  enter  into  the  matter,  however.  Recov- 
ery from  chloroform  is  more  rapid  than  from  ether.  The  reco^•ery 
will  be  shorter  if  the  administration  has  been  even;  if  a  good  quality 
of  ether  has  been  used;  if  the  patient  has  been  at  all  times  allowed 
sufficient  oxygen;  if  the  air-passages  have  not  been  plugged  with  mucus; 
if  the  circulation  has  been  well  maintained  during  the  anesthesia; 
if  the  patient  has  not  vomited  during  the  administration,  or  any  emer- 
gency has  arisen  necessitating  the  use  of  tongue-forceps  (Fig.  11)  or  of 


3° 


ANESTHESIA — AFTER    THE    ANESTHETIC 


artificial  respiration.  A  skilful  anesthetist  will,  at  the  end,  have  his 
subject  so  lightly  under  the  influence  of  the  anesthetic  that  signs  of 
recovery   appear   immediately   upon  transference  from   table   to  bed. 


Fig.  II. — Tongue-forceps  and  Mouth-gag. 


Some  operators,  indeed,  demand  of   their  etherizers  that  the  patient 
vomit  before  he  leaves  the  table;  this  is  of  particular  advantage  in  private- 


FiG.  12. — From  Operating-room  to  Bed. 
Patient  protected  from  exposure  and  properly  attended. 

house  operations,  where  the  surgeon  is  usually  loathe  to  leave  until  he 
is  assured  that  recovery  is  well  under  way. 

The  anesthetist,  should  in  e^•ery  case  see  the  patient  to  bed,  and 
stay  by  him  until  distinct  signs  of  recovery  are  evident — until  the  patient 


AFTER   THE   ANESTHETIC 


31 


is  able  to  dispose  of  his  vomitus.  He  should  remain  until  some  semi- 
voluntary  action  takes  place— until  the  patient  turns  his  head,  opens 
his  eyes,  moans,  or  talks.  In  certain  types  of  cases  temporary  obstruc- 
tion of  respiration  is  likely  to  occur,  and  there  must  be  some  one  at  hand 
who  is  competent  to  use  the  mouth-gag  and  tongue- forceps  in  an  emer- 
gency, who  will  hold  forward  the  jaw,  wipe  away  the  frothy  mucus, 
and  clear  the  mouth  of  vomitus  if  necessary.  Neglect  of  this  precaution 
may  be  serious,  either  as  regards  immediate  strangulation  or  subsequent 
pneumonia.  When  a  patient  responds  in  any  way  to  the  question 
"Feeling  better?"  he  may  be  safely  left  with  a  nurse. 

If  the  patient  remains  for  a  long  time  after  the  operation  in  a  state  of 
deep  narcosis,  it  means  that  an  unnecessarily  large  amount  of  anesthetic 


Fig.  13. — From  Operating-room  to  Bed. 
Exposure  and  neglect  of  patient;  vomiting  unattended. 

has  been  used.  Accompanying  this  prolonged  stupor  there  will  be  a 
deterioration-  in  the  pulse  and  duskiness  of  the  face  and  lips.  Some- 
times, however,  even  if  an  excessive  quantity  of  the  anesthetic  has  not 
been  used,  there  will  appear  a  slighter  degree  of  duskiness  and  some 
flagging  of  the  pulse,  independent  of  length  or  seriousness  of  operation, 
which  is  probably  due  to  the  presence  of  mucus  in  the  air-passages 
and  to  the  deprivation  of  the  stimulating  action  of  the  anesthetic.^ 

*  J.  B.  Blake  (Boston  Med.  and  Siirg.  Jour.,  1896,  c.xxxv,  492):  "Oxygen  shortens  the 
time  of  returning  consciousness  and  diminishes  unpleasant  after-effects  of  ether.  It  is  a 
good  cardiac  and  respiratory  stimulant,  and  is  indicated  in  threatened  collapse.  Insert  a 
soft-rubber  catheter  gently  through  the  nares  until  the  eye  is  approximately  opposite  the 
opening  in  the  trachea." 


^2  ANESTHESIA — AFTER    THE    ANESTHETIC 

Both  chloroform  and  ether  act  as  cardiac  stimulants  in  feeble  sub- 
jects, and  as  soon  as  their  administration  is  stopped,  the  circulation  will 
flag.  During  the  interval  of  lowered  vitality  the  patient  should  be  kept 
dry  and  warm.  As  soon  as  retching  and  vomiting  occur  and  the  air- 
passages  have  cleared  themselves  of  their  accumulations,  the  normal 
color  will  come  back  to  the  face  and  lips  and  the  pulse  will  be  restored  to 
its  former  strength. 

The  best  position  for  a  speedy  and  satisfactory  recovery  is  with 
the  patient  on  his  side.  \A"hen  conditions  allow  this — and  the  excep- 
tions are  rare — it  will  be  found  that  the  tongue  gravitates  to  the  side 
of  the  mouth,  a  free  air-way  is  established,  stertor  disappears,  mucus  and 
saliva  will  find  their  way  out  without  being  sucked  into  the  air-pas- 
sages, and  coughing  ceases;  if  there  is  vomiting,  the  vomitus  will  escape 
freely.  The  patient,  having  no  pillow  under  his  head,  may  be  bolstered 
up  if  turned  on  his  right  side  by  putting  a  doubled  pillow  behind  his 
left  shoulder,  taking  the  precaution  of  making  sure  that  he  is  not  lying 
upon  his  right  arm.  When  the  patient  cannot  be  turned,  his  head  should 
be  held  to  the  right. 

NAUSEA  AND  VOMITING 

The  occurrence  of  nausea,  retching,  or  vomiting  in  some  degree  is 
characteristic  of  the  after-effects  of  ether.  It  comes  on  suddenly,  and 
for  the  time  being  it  may  be  violent,  but  subsides  rapidly  and  leaves 
the  patient  half  awakened  to  clear-headed  consciousness,  or  is  suc- 
ceeded by  quiet,  normal  sleep.  Vomiting  after  ether  practically  always 
is  temporary ;  as  a  rule,  it  occurs  while  the  patient  is  unconscious,  and 
has  spent  itself  before  the  patient  has  been  brought  to  a  state  of  reali- 
zation of  his  distress.  It  may,  however,  recur  in  repeated  attacks, 
and  this  depends  on  certain  factors  which  should  be  mentioned. 

If  solids  or  liquids  are  present  in  the  stomach  at  the  beginning  of 
the  administration,  there  will  not  only  be  difficulty  in  maintaining  a 
deep,  even,  quiet  anesthesia,  but  the  after-symptoms  may  be  severe. 
The  quality  of  ether  used  is  important — it  should  be  made  from  pure 
grain  alcohol,  free  from  methylic  ether,  sulphuric  acid,  alcohol,  or 
water;  it  should  be  freshly  opened,  for  ether  exposed  to  the  air  develops 
acetic  acid. 

If  during  the  operation  much  blood,  mucus,  or  saliva  passes  into  the 
stomach,  it  will  be  bound  to  find  its  way  up  in  the  post-anesthetic  stage. 
The  after-symptoms  are  likely  to  be  more  severe  in  constipated  persons, 
after  handling  of  the  stomach  or  intestines,  if  the  anesthesia  is  pro- 
tracted, or  if  the  patient  is  jolted  about  during  recovery.     Some  surgeons 


C^ 


NAUSEA   AND    VOMITING  2;^ 

make  it  a  practice  to  wash  out  the  stomach  after  the  operation  is  over 
while  the  patient  is  still  on  the  table;  this  often  is  advantageous,  espe- 
cially in  cases  where  proper  preparation  has  not  been  possible,  in  that  it 
forestalls  what  may  prove  to  be  an  uncomfortable  period  for  the  patient. 
As  a  routine  its  employment  is  unnecessary.^ 

^  Blumfeld  (Med.  Press  and  Circ.,  1909,  n.  s.  Ixxxvi,  605,  Nature  of  Vomiting  after 
Anesthesia,  with  Suggestions  for  Its  Treatment):  "The  most  rational  way  to  treat  and  pre- 
vent nausea  and  vomiting  after  anesthesia  is  to  promote  the  elimination  of  the  circulating 
anesthetic.  Secretion  through  the  skin  and  the  kidneys  should  be  assisted,  patient  should 
be  kept  warm,  and  a  saUne  enema  administered  or  salt  solution  given  under  the  skin. 
Nothing  should  be  put  into  the  stomach.  The  only  call  is  that  of  thirst,  and  this  gives  no 
trouble  if  salt  solution  is  supplied  by  rectum  or  subcutaneous  injection.  Washing  out 
the  mouth  with  lemon  juice  and  water  is  pleasant  for  the  patient  and  helps  to  allay  feel- 
ings of  thirst.  Preventive  treatment  with  glucose,  based  on  chemic  theories  explaining 
chloroform  poisoning,  has  been  given  a  trial  at  St.  George's  Hospital.  The  results  show 
no  alteration  of  the  ordinary  percentage  of  after-sickness." 

Ochsner  (Clin.  Surg.,  1902,  108,  et  seq.):  "The  fact  that  the  patient  is  suffering  from 
nausea  or  vomiting  is  the  strongest  indication  for  the  use  of  gastric  lavage,  because  the 
nausea  is  caused  by  the  presence  of  decomposing  material  in  the  stomach,  and  its  re- 
moval must  result  in  the  greatest  benefit  to  the  patient.  It  frequently  happens  that 
these  patients  lose  their  anxious  expression  and  restlessness,  which  we  have  observed  in  this 
case,  and  that  the  skin  becomes  warm  and  moist,  and  they  begin  to  sleep  directly  after  the 
gastric  lavage  has  been  practised.   .  .  . 

"  It  is  possible  that  there  may  be  more  material  of  the  same  character  in  the  small  intes- 
tines, but,  if  so,  it  will  soon  regurgitate  into  the  stomach  and  make  its  presence  known  by 
the  recurrence  of  nausea.  Should  this  occur,  the  gastric  lavage  will  b*e  repeated  at  once. 
If  no  food  is  given  by  mouth,  I  have  never  been  compelled  to  irrigate  the  stomach  more 
than  two  or  three  times  in  the  same  patient,  and  usually  one  careful,  thorough  irrigation 
will  sufiSce.  It  will  be  wise  to  direct  attention  to  the  method  employed  in  such  cases.  The 
patient  is  turned  upon  the  right  side  in  order  to  add  the  weight  of  the  intestines  to  the 
support  of  any  adhesions  which  may  exist  in  the  vicinity  of  the  appendix.  The  head  and 
shoulders  are  slightly  elevated  by  means  of  pillows  or  a  head-rest,  then  the  pharynx  is 
sprayed  with  a  4  per  cent,  solution  of  cocain  in  order  to  prevent  gagging  when  the  stomach- 
tube  is  passed,  because  this  might  disturb  the  adhesions  in  the  vicinity  of  the  appendix. 
It  is  well  to  spray  the  pharynx  repeatedly  for  a  period  of  about  five  minutes,  permitting  the 
patient  to  swallow  a  little  of  the  saliva  mixed  with  cocain  in  order  to  anesthetize  the  esopha- 
gus to  some  extent  at  the  same  time.  After  holding  the  cocain  in  the  pharynx  a  minute 
it  is  expectorated  with  the  saliva  which  has  accumulated  and  a  fresh  spray  is  applied.  As 
most  of  the  cocain  is  thus  thrown  out,  there  is  no  danger  from  poisoning.  After  about 
five  minutes  a  fairly  large  stomach-tube  is  inserted  and  the  contents  of  the  stomach  siphoned 
out.  The  stomach-tube  should  have  one  or  two  lateral  openings  aside  from  the  opening  at 
its  end.  These  openings  should  be  within  i  to  2  inches  from  the  end  which  is  inserted  in 
the  stomach.  This  will  prevent  the  end  of  the  tube  from  becoming  closed  by  drawing 
into  it  a  portion  of  the  mucous  lining  of  the  stomach. 

"Whenever  there  is  any  interruption  in-the  flow,  this  may  be  overcome  by  pouring  a 
little  water  into  the  tube  and  thus  dislodging  any  substance  which  may  have  become 
fixed  therein. 

''After  the  accumulation  which  is  present  in  the  stomach  has  been  siphoned  out  it  is 
well  to  introduce  into  the  stomach  i  pint  of  normal  salt  solution  at  100°  F.  and  then 
siphon  it  out.     This  may  be  repeated  until  the  fluid  returns  clear. 

"The  patient  will  now  be  placed  in  bed,  with  the  shoulders  somewhat  elevated,  so  as 

3 


34  ANESTHESIA AFTER   THE   ANESTHETIC 

Chloroform  in  this  respect  acts  differently  from  ether.  The  transient 
nausea,  with  retching,  ending  in  the  expulsion  of  a  small  quantity  of 
whitish  or  yellowish  stringy  fluid,  rarely  occurs,  owing  chiefly,  perhaps, 
to  the  smaller  quantities  of  mucus  which  are  secreted  under  the  stim- 
ulation of  chloroform.  If  the  chloroform  anesthesia  has  been  main- 
tained evenly  and  deeply,  the  recovery,  as  a  rule,  is  rapid  and  satis- 
factory— a  single  cough  or  act  of  retching  will  sufiice  to  clear  the  larynx 
of  any  mucus-plug,  the  dusky  hue  will  depart  from  face  and  lips,  the 
pulse  will  rapidly  restore  itself,  and  the  patient,  if  not  disturbed,  will 
usually  pass  off  into  a  quiet  sleep.  When,  however,  vomiting  does 
come  on  after  chloroform  it  is  much  more  likely  to  prove  distressing  to 
the  patient  and  intractable  to  treatment;  indeed,  fatal  cases  have  been 
reported.  It  is  apt  to  occur  at  intervals  for  hours  and  sometimes  days, 
even  after  the  stomach  has  emptied  itself  beyond  any  possibility  of 
doubt,  which  leads  to  the  inference  that  it  is  due  to  some  not  clearly 
evident  reflex  mechanism.  As  against  the  brisk  but  transient  gastric 
disturbance  of  ether,  the  more  rare  but  persistent  retching  of  chloroform 
is  far  w^orse.^ 

It  must  not  be  overlooked  that  the  vomiting  following  operation 
may  have  a  significance  of  its  own,  apart  from  the  anesthetic.  It  may 
be  a  symptom  of  intestinal  obstruction  or  peritonitis,  in  which  case  its 
character  and  appearance  are  of  importance;  it  may  be  an  early  mani- 


to  favor  gravitation  toward  the  pelvis.  She  vdW  receive  absolutely  no  food  and  no  cathar- 
tics by  mouth.  Every  four  hours  she  ydW  receive  an  enema  of  i  ounce  of  one  ot  the  con- 
centrated predigested  foods  dissolved  in  3  ounces  of  normal  salt  solution.  I  am  confident 
that  she  will  not  require  any  anodyne,  her  pain  will  disappear  spontaneously,  since  we  have 
removed  the  cause  of  irritation  by  performing  gastric  lavage.    .    .    . 

"There  are  two  classes  of  patients  in  whom  this  form  of  treatment  is  not  so  satisfactory 
as  it  is  in  all  other  classes — namely,  the  very  old  and  the  very  young.  Very  old  patients 
do  not  bear  confinement  in  bed  well,  no  matter  what  their  condition  may  be,  and  they 
do  not  prosper  generally  on  rectal  feeding.  In  these  cases  one  is  compelled  to  choose 
between  two  evils,  and  whichever  is  chosen,  one  usually  ■w'ishes  it  had  been  the  other. 

"In  children  it  is  difiicult  to  perform  gastric  lavage;  they  are  likely  to  struggle  and  injure 
themselves  while  this  is  being  accomplished." 

^  Blanlaret  (Pressg  Med.,  1909,  xvii,  481,  "  Vomissements  Chloroformiques")  "Vomit- 
ing from  chloroform  is  annojing,  threatens  the  solidity  of  the  suture,  weakens  the  patient, 
and  by  inhalation  of  solid  or  fluid  particles  causes  postoperative  pneumonia  and  bron- 
chitis. The  patient  should  be  kept  under  the  influence  of  the  anesthetic  until  he  is 
safely  returned  to  bed,  because  movement  of  the  body,  especially  when  the  anesthesia 
is  not  complete,  increases  the  tendency  to  vomiting.  Of  equal  importance  is  the  main- 
tenance of  an  even  temperature,  of  the  body  and  the  removal  of  the  patient  from  an 
atmosphere  charged  with  chloroform.  Lavage  of  the  stomach  before  the  patient  regains 
consciousness  may  be  advisable  if  there  has  been  much  secretion  and  swallowing  of 
saliva.  If  vomiting  occurs,  cold  applications  to  the  stomach  or  injections  of  ergot  or  of 
picrotoxin,  i  cc.  of  a  2  per  cent,  solution." 


RECOVERY  ROOM 


35 


festation  of  pneumonia  or  uremia.  Sometimes  vomiting  will  apparently 
be  continued  as  a  reflex  from  the  pressure  of  gauze  drainage  or  of  a 
glass  tube;  sometimes  it  will  be  kept  up  by  improper  food  supplied  by 
injudicious  friends.  Some  observers  state  that  a  dose  of  morphin 
and  atropin  (morphin,  gr.  g  to  ^;  atropin  sulphate,  gr.  y^  to  yu^)  or 
scopolamin,  given  by  mouth  or  hypodermically  one-half  hour  preceding 
the  administration  of  an  anesthetic,  will  shorten  the  time  necessary 
for  getting  a  patient  under,  will  render  the  anesthesia  more  quiet,  and 
will  lessen  to  a  great  degree  the  after-effects.  I  do  not  advise  this  as  a 
routine.  In  alcoholics,  dyspeptics,  and  the  nervously  unstable  we  have 
undoubtedly  an  indication  for  some  such  treatment.  After  anesthesia, 
if  the  vomiting  is  protracted  or  violent  and  there  is  danger  of  the  slipping 
of  a  ligature  or  of  too  much  strain  being  placed  on  a  long  abdominal 
wound,  it  is  advisable,  if  none  has  been  given  for  three  or  four  hours,  to 
administer  a  suitable  dose  of  morphin  hypodermically. 

RECOVERY  ROOM 

To  aid  an  unconscious  person  to  vomit  the  head  should  not  merely 
be  turned  over,  but  the  patient  should  be  lifted  by  the  shoulder  over  on 
the  side  imtil  the  thorax  is  well  turned.  If,  then,  with  the  chin  pulled 
forward,  reflex  expulsive  effort  is  not  sufficient  to  drive  the  vomitusi 
out  of  the  pharynx  and  mouth,  inspiration  involuntarily  follows,  and 
the  vomited  matter  is  pulled  back  toward  the  trachea.  The  first 
danger  from  vomiting  after  ether  is  that  the  vomitus  shall  enter  the 
trachea  and  acutely  interfere  with  respiration — in  short,  choke  the 
patient.  Should  a  patient,  therefore,  be  seen  to  make  a  vomiting  effort, 
h'ttle  or  nothing  come  out  of  the  mouth,  and  cessation  of  breathing  with 
cyanosis  appear,  the  air-passages  above  the  larynx  must  be  cleared  at 
once  by  the  deep-reaching  finger  or  swab.  Obstruction  may  be  due 
to  the  tongue  being  sucked  backward  into  the  pharynx — a  matter 
quickly  remedied. 

If  the  vomited  matter  has  been  inspired  deeper  than  the  larynx,  and 
the  reflex  coughing  is  not  sufficient  to  clear  the  trachea,  tracheotomy 
must  be  done  at  once. 

As  a  rule,  a  patient  vomits  most  easily  with  head  low,  that  is  to  say, 
without  a  pillow.  It  is  said  that  lying  on  the  right  side  diminishes  the 
tendency  to  vomit,  as  the  contents  of  the  stomach  move  over  toward  the 
right  orifice  and  will  not  so  easily  be  ejected.  It  should  not  be  forgotten, 
however,  that  during  anesthesia  ether  is  excreted  by  the  stomach,  and 
hence  the  stomach-contents  must  contain  a  certain  amount  of  irritative 
ether.     Some  vomiting,  therefore,  is  desirable. 


36  ANESTHESIA — AFTER   THE   ANESTHETIC 

A.  Graham*  recommends  the  administration  of  i  ounce  of  pure 
olive  oil  just  as  soon  as  the  patient  can  swallow.  He  reports  that  in 
29  out  of  30  cases  there  was  no  vomiting  after  this  procedure.  The  oil 
is  supposed  to  dissolve  the  ether  within  the  stomach. 

Vomiting  persistent  for  several  hours  after  ether  becomes  an  impor- 
tant factor  in  recovery,  and,  even  supposing  it  to  be  due  to  the  surgical 
condition  or  only  to  an  ether  idiosyncrasy,  it  may  so  exhaust  the  patient 
as  to  turn  the  balance  against  him. 

The  treatment  of  protracted  vomiting  is  sometimes  unsatisfactory, 
but  ordinarily  after  ether  comparatively  simple  measures  will  giye  relief. 
It  is  fair  to  say  that  a  patient  adequately  prepared  for  operation  by 
rest  in  bed  and  thorough  emptying  of  the  alimentary  tract  vomits  the 
least  after  ether,  but  it  should  not  be  forgotten  that  excessive  nausea 
after  ether  may  be  an  individual  peculiarity  that  no  amount  of  prepara- 
tion will  counteract  in  a  given  case.  Frequent  rinsing  of  the  mouth 
with  cold  water  should  be  tried,  but  ice  increases  the  tendency  to  vomit- 
ing. Five  to  15  min.  of  cocain  hydrochlorid,  2  per  cent,  solution,  in  i 
dram  of  hot  water  every  half-hour  for  three  or  four  doses,  will  sometimes 
allay  a  most  persistent  case. 

By  far  the  best  and  simplest  procedure  is  to  give  the  patient,  three  or 
four  hours  after  operation,  or  as  soon  as  he  asks  for  it,  a  glassful  of  hot 
water  (a  half  pint).  This  will  promptly  make  him  sick,  and  he  will 
vomit  it,  together  with  the  mucus  and  saliva  and  the  ether  which  he  has 
swallowed  as  vapor,  or  which  has  been  reexcreted  by  the  gastric  mucous 
membrane.  This  is,  in  short,  an  effectual  form  of  gastric  lavage;  the 
stomach,  which  has  been  ineffectually  retching  in  an  effort  to  bring  up 
a  small  quantity  of  thick,  slimy,  irritating  material,  now  successfully 
exerts  itself  in  getting  rid  of  a  larger  bulk  of  more  dilute  fluid.  Later 
another  drink  may  be  given,  and  it  will  usually  be  retained.  This  pro- 
cedure is  contra-indicated  only  in  certain  operations  involving  the 
stomach  and  duodenum.  If  the  vomiting  is  still  persistent  and  prolonged 
— that  is,  after  five  or  six  hours,  and  is  not  then  delinitely  becoming 
less  frequent — the  stomach  should  be  washed  out  with  hot  water  contain- 
ing sodium  bicarbonate,  i  dram  to  the  quart.  This  lavage  may  be 
repeated  every  four  hours  if  vomiting  persists. 

Although  washing  out  the  stomach  is  an  uncomfortable  procedure 
for  the  patient,  it  is  brief  and  most  efficiently  relie^'es  the  symptoms. 
The  tube  should  be  passed  rapidly  well  into  the  stomach,  and  as  much 
sodium  bicarbonate  solution  (4  drams  to  i  quart)  as  the  stomach  will 
comfortably  hold  is  passed  in.     This  is  forthwith  siphoned  out,  and  the 

*  Jour.  Am.  Med.  Assoc,  1909,  liii,  2094.   . 


RECOVERY   ROOM  37 

stomach  is  so  filled  and  emptied  three  times.  Just  before  the  tube  is 
withdrawn  a  small  amount  of  the  alkaline  solution  is  left  in.  This 
method  is  better  than  any  of  the  medical  remedies. 

Charged  waters  and  champagne  seem  to  exert  a  quieting  effect  upon 
the  stomach.  Essence  of  peppermint,  5  to  10  drops  on  a  lump  of  sugar 
or  in  water,  may  often  be  of  benefit,  as  well  as  tincture  of  capsicum  or 
tincture  of  iodin,  2  or  3  drops  in  water.  Hot  fomentations  or  hot-water 
bag,  or,  much  less  commonly,  the  ice-bag  over  the  epigastrium,  may 
relieve  the  stomach  spasm.  The  inhalation  of  vinegar  is  said  to  have  a 
sedative  effect  in  vomiting  after  ether. 

If  the  vomiting  does  not  yield  to  these  milder  measures  after  a 
reasonable  time,  it  is  likely  to  prove  troublesome.  The  patient  should 
be  kept  in  a  quiet,  darkened  room,  propped  up  in  a  sitting  posture  in 
bed,  and  all  food  and  drink  by  mouth  stopped.  Any  residue  in  the 
stomach  should  be  gotten  rid  of  by  means  of  gastric  lavage.  Nourish- 
ment should  be  administered  only  by  way  of  rectum.  A  mustard  plaster 
should  be  applied  to  the  epigastrium,  or  a  hot-water  bag  should  be  ap- 
plied and  frequently  renewed.  Morphin  will  be  of  service,  or  a  cup  of 
black  coffee  to  which  10  gr.  of  sodium  bromid  has  been  added  may  be 
given.  Milk  of  bismuth  in  ounce  doses  may  be  repeated  frequently. 
Cocain,  gr.  y\j-  (5  min.  of  2  per  cent,  solution),  may  be  given  every 
half-hour.  Cerium  oxalate,  gr.  5  to  10;  sodium  bromid,  gr.  20  in 
water;  chloroform,  i  min.  in  a  teaspoonful  of  water;  dilute  hydrocyanic 
acid,  I  or  2  min.  in  water,  have  all  been  recommended.  C.  Ritter^ 
advises  the  use  of  a  Bier  constriction-band,  applied  to  the  neck  immedi- 
ately after  the  close  of  the  operation,  left  in  place  for  one-half  to  one 
hour. 

A  drainage-tube  in  the  abdominal  cavity  may  produce  continued 
reflex  vomiting,  which  will  cease  upon  removal  of  the  tube.  Elevation 
of  the  head  will  often  reduce  the  sensation  of  nausea. 

Technique  of  Emergency  Tracheotomy.— The  head  is 
dropped  into  the  Rose  position — that  is  to  say,  backward  over  the  edge 
of  the  bed  or  table.  Standing  on  the  patient's  right  the  surgeon,  with  the 
left  thumb  and  forefinger,  grasps  the  cricoid  and  upper  trachea,  holding 
it  firm  in  the  middle  line.  With  the  right  hand  an  incision  is  made  with  a 
pocket-knife  or  any  cutting  instrument  which  it  is  possible  to  get,  from 
just  below  the  cricoid,  i  to  i^-  inches  downward,  if  possible  at  once  to 
the  depth  of  the  trachea  itself.  Bleeding  is  absolutely  disregarded. 
The  knife,  now  turned  edge  toward  the  patient's  chin,  slipped  into  the 
trachea  at  the  bottom  of  the  wound,  cuts  upward  about  three  tracheal 

^  Zeit.  f.  Chir.,  1908,  xxxv,  860. 


38  ANESTHESIA — AFTER   THE   ANESTHETIC 

rings.     The  knife  turned  at  right  angles  will  hold  open  the  tracheal 
wound  while  artificial  respiration  helps  the  patient  to  breathe. 

When  this  operation  is  started,  some  bystander  should  at  once  go  for 
the  tracheal  dilator  and  two  or  three  tracheal  cannulae,  and  when  they 
arrive,  one  of  the  tubes  may  be  inserted,  a  tube  sufficiently  long  to  well 
enter  the  trachea,  but  not  long  enough  to  cause  pressure  deep  in  the 
trachea  where  it  is  in  relation  to  the  arch  of  the  aorta.  The  tube  at 
first  rapidly  fills  with  blood  or  mucus.  This  is  best  cleared  by  rotating 
a  hen's  feather  down  through  the  tube.  When  respiration  is  well 
established,  any  part  of  the  wound  extending  above  and  below  the 
bleeding  of  the  tracheal  tube  may  be  closed  with  sutures. 

HEMATEMESIS 

The  vomiting  of  blood  after  operation,  where  no  lesion  in  the  gastro- 
intestinal tract  exists  to  explain  its  occurrence,  was  first  noted  thirty- 
eight  years  ago,^  and  it  has  never  yet  been  satisfactorily  explained.  Cases 
are  not  frequent  in  the  literature,  but  they  have  been  recorded  by 
A.  V.  Eiselsberg,^  C.  W.  Mansell-Moullin,^  A.  W.  Mayo-Robson,*  J.  H. 
Croom-,^  W.  E.  Lee,^  and  others. 

Hematemesis  occurs  practically  only  after  celiotomy.  The  opera- 
tion need  not  have  been  performed  on  the  gastro-intestinal  tract,  for  it 
has  followed  cases  of  ovariotomy,  hernia,  pelvic  abscess,  peritonitis,  and 
cholecystotomy.  General  anesthesia  is  not  a  necessary  antecedent,  nor 
does  the  presence  or  absence  of  sepsis  seem  to  have  any  bearing  upon 
the  etiology. 

Von  Eiselsberg  considered  that  the  condition  was  the  result  of  torsion 
or  ligature  of  the  omentum,  causing  multiple  gastric  hemorrhages. 
McKay  suggests  that  a  common  factor  in  all  cases  is  shock,  and  that 
shock  may  produce  portal  engorgement  and,  secondarily,  venous  conges- 
tion of  the  walls  of  the  stomach,  and  that  diapedesis  or  even  rupture  of 
the  capillaries  may  result.  Others  have  suggested  that  the  hemorrhage 
is  the  result  of  operative  trauma  to  the  gastro-intestinal  tract,  that  it 
is  caused  by  thrombosis,'  or  that  it  is  the  result  of  multiple  infective 
emboli  from  any  source  of  infection,  such  as  the  appendix  or  gall-bladder, 
set  free  by  the  manipulation  attending  operative  procedure  and  dis- 
tributed by  the  blood-stream. 

^  Fox,  Diseases  of  the  Stomach,  1872,  p.  205,  quoted  by  McKay. 
^  Archiv  f.  klin.  Chir.,  1899,  Hx,  832. 

^Lancet,  1900.  ii,  1125.  ■*  Ibid.,  1901,  i,  375. 

^  Brit.  Gyn.  Jour.,  1902,  xviii,  59.  ®  Ann.  Surg.,  190S,  xh-iii,  632. 

'  Schwellbach,  Postoperative  Gastro-intestinal  Hemorrhage  After  Appendix  Opera- 
tions, Deutsch.  Zeit.  f.  Chir.,  1908,  xcv,  141. 


RESTLESSNESS  39 

It  is  not  uncommon  to  note  that  a  patient  who  has  just  undergone  a 
severe  operation,  particularly  one  who  has  taken  his  ether  badly,  while 
coming  out  will  vomit  a  small  amount  of  brownish,  frothy  fluid.  This 
is  always  transient,  and  it  represents  the  small  amount  of  blood  which 
is  swallowed  during  the  operation  and  digested  in  the  stomach.  Post- 
operative hematemesis  may  come  on  a  few  hours  after  the  patient  has 
recovered  from  the  anesthetic,  or  its  onset  may  be  postponed  a  day  or  so. 
The  blood  may  be  bright  red  in  color,  but  it  is  more  likely  to  present 
some  degree  of  decomposition,  varying  in  shade  from  light  brown  to 
black.  The  fluid  contains  brown,  flocculent  masses,  and  responds  to  the 
tests  for  the  recognition  of  blood.  The  vomitus  may  be  small  in  quantity 
and  frequently  repeated,  or  the  patient  may  vomit  but  once  or  twice  a 
considerable  quantity — from  a  pint  to  a  quart  at  a  time.  Sometimes  the 
vomiting  is  accompanied  by  the  passage  of  blood  per  rectum.  The 
general  condition  resembles  that  of  profound  collapse. 

The  prognosis  in  all  cases  is  poor.  As  stated  by  Lee  (loc.  cit),  the 
mortality  has  been  placed  at  55  and  72^  per  cent.  If  the  hemorrhage  is 
in  small  quantity  and  digested,  rather  than  in  larger  quantity  of  fresh 
blood,  the  pulse  is  more  likely  to  maintain  its  tone  and  collapse  is  less 
to  be  feared. 

Treatment  promises  little.  Morphin  should  be  administered  to  keep 
the  patient,  and  particularly  his  gastro-intestinal  tract,  quiet.  Nothing 
should  be  given  by  mouth — saline  solution  and  a  nutrient  enema  when 
indicated  should  be  given  by  rectum.  Saline  with  adrenalin  should  also 
be  given  subcutaneously  if  there  are  signs  of  collapse.  Hot  gastric 
lavage  has  been  recommended;  saline  solution  at  a  temperature  of  115° 
F.  should  be  used.  After  this  comes  back  clear  15  min.  of  adrenalin  in  i 
pint  of  normal  salt  solution  can  be  poured  in  and  left. 

RESTLESSNESS 

Restlessness  is  due  most  often  to  the  mild  delirium  from  ether  and 
to  petty  discomforts;  next,  to  pain.  It  is  always  present  after  serious 
loss  of  blood  and  is  frequently  present  in  shock.  The  restlessness  of 
hemorrhage  and  shock  is  considered  elsewhere;  that  due  to  pain  will 
be  discussed  later. 

The  restlessness  due  to  ether  soon  passes  off.  It  closely  resembles 
a  delirium;  the  patient  acts  wildly,  is  very  talkative,  sometimes 
screaming  and  thrashing  about  violently.  If  his  attention  can  once 
be  secured,  he  becomes  quiet,  and  often  confesses  to  acting  queerly 
without  cause.  As  a  rule,  this  foretells  the  end  of  the  delirium,  but 
frequently  it  is   necessary  to  hold   the  attention   for  a  few  moments. 


40  ANESTHESIA — AFTER   THE   ANESTHETIC 

Sometimes  he  relapses  into  delirium,  but  is  readily  made  rational  by 
the  same  means. 

The  petty  discomforts  causing  restlessness  are  numerous.  Often  the 
worry  and  anxiety  incident  to  the  operation  are  the  cause.  Whatever 
the  result  of  the  operation  may  be,  assure  the  patient  for  the  time  being 
that  everything  is  as  favorable  as  could  be  expected;  tactfully  allay  his 
suspicions  and  anxieties  and  encourage  him  not  to  talk. 

The  relief  of  nausea  and  thirst  is  generally  followed  by  satisfaction 
of  mind  and  body.  A  slight  change  in  posture;  a  pillow  under  the  small 
of  the  back  or  under  the  knees;  a  blanket  less  or  a  blanket  more;  the 
loosening  of  a  tight  binder,  or  the  granting  of  a  harmless  whim,  will 
often  allay  the  restlessness.  Not  rarely  a  heater  has  caused  a  burn, 
slight  but  nevertheless  irritating,  proper  attention  to  which  is  gratifying 
and  restful  to  the  patient.  See  that  the  patient  is  dry  throughout,  and 
that  his  wound  is  free  from  unnecessary  pressure  and  strain.  If  the 
patient  has  recovered  from  his  ether,  and  the  simple  measures  described 
above  have  failed  to  quiet  him,  the  cause  of  his  restlessness  is  probably 
more  serious,  and  should  be  found  and  treated  accordingly. 

SWEATING 

In  most  cases  ether,  by  dilating  the  superficial  capillaries,  induces 
sweating.  This  commonly  occurs  early  in  anesthesia,  and  ceases  as  the 
circulation  regains  its  equilibrium.  In  strong,  healthy  patients  it  rarely 
has  any  untoward  significance.  This  sweating  may  be  called  physiologic, 
in  that  it  is  eliminative  and  harmless,  provided  the  body  surface  is  guarded 
from  sudden  chilling.  Therefore,  in  the  recovery  room  even  profuse 
sweating  in  itself  need  cause  no  alarm  in  the  case  of  a  vigorous  person, 
or  in  cases  where  the  operation  has  been  short.  Toward  the  end  of  a 
long  operation,  or  when  the  patient  has  been  some  little  time  in  the 
recovery  room,  sweating  occasionally  appears.  This  is  a  cold,  rather 
scanty,  and  clammy  sweat,  of  far  different  aspect  and  graver  significance 
than  the  other  variety.  It  is  a  sign  of  weakness,  and  should  call  atten- 
tion at  once  to  the  patient's  general  condition.  Shock  and  hemorrhage 
are  both  to  be  looked  for,  and  measures  taken  at  once  to  support  the 
patient.  It  is  an  early  danger-signal  of  considerable  value,  and  while 
it  may  not  be  followed  by  a  serious  condition,  it  is  by  no  means  to  be 
disregarded. 


CHAPTER    III 

THIRST,  ITS  SIGNIFICANCE  AND  RELIEF 

The  sensation  of  thirst  which  is  commonly  complained  of  after 
operations,  especially  laparotomies,  sometimes  assumes  troublesome 
proportions.  Thirst  is  partly  symptomatic;  the  inhalation  of  ether  or 
chloroform  seems  to  exert  a  postanesthetic  inhibitory  action  on  the 
secretion  of  the  mucous  glands  of  the  mouth  and  throat,  and  anesthesia, 
especially  if  there  is  any  manipulation  of  the  stomach  and  intestines, 
seems  to  be  followed  by  a  reflex  decrease  in  the  secretion  of  saliva,  so 
that,  as  a  result,  the  patient  suffers  from  a  dryness  of  the  mouth  and 
fauces  and  begs  for  water.  This  same  condition,  moreover,  may  be  due 
in  part  or  chiefly  to  the  action  of  morphin  or  atropin  administered  before, 
during,  or  after  the  operation.  Thirst  may,  without  doubt,  result 
also  from  an  actual  loss  of  body  fluids — by  a  purge  before  operation, 
by  increased  secretion  of  mucus  and  saliva  under  the  anesthetic,  and 
by  vomiting,  sweating,  or  hemorrhage  during  or  after  the  operation. 

Operations  involving  the  peritoneum  are  practically  always  followed 
by  the  symptom  thirst,  due  to  loss  of  body  fluids,  as  shown  by  an  increase 
(which  has  been  demonstrated  experimentally)  in  the  specific  gravity 
of  the  blood;  intense  thirst  usually  also  characterizes  the  condition  of 
shock,  and  occurs  generally  in  peritonitis  and  to  a  less  degree  in  febrile 
temperature  from  any  cause.  Thirst  ceases  as  soon  as  the  body  tissues 
have  been  provided  with  their  proper  complement  of  fluid. 

The  condition  of  thirst  may  be  met  by  the  use  of  drinks,  washing 
of  the  mouth,  by  enemas,  by  leaving  water  in  the  abdomen  before  sewing 
up  after  celiotomy,  and  by  the  use  of  water  subcutaneously. 

By  mouth,  as  already  stated,  there  is  very  rarely  any  contra-indication 
to  giving  water  in  considerable  quantities.  If  the  patient  is  nauseated 
after  the  anesthetic,  and  water  in  copious  draughts  seems  temporarily  to 
increase  his  vomiting,  it  must  be  borne  in  mind  that  the  water  is  serving 
to  wash  out  the  stomach  and  to  hetp  it  relieve  itself  of  an  irritating  sub- 
stance. If  the  patient  is  vomiting  from  any  other  cause,  and  it  becomes 
important  to  supply  fluids  to  the  body,  it  will  be  found  usually  that  the 
water  is  retained  sufficiently  long  to  allow  a  considerable  portion  of  it  to 
be  absorbed.     In  either  case  the  giving  of  small  sips  of  water,  frequently 

41 


42  THIRST,    ITS    SIGNIFICANCE   AND    RELIEF 

repeated,  is  to  be  condemned,  for  such  a  method  is  apt  to  provoke  vomit- 
ing where  it  does  not  already  exist,  and  is  ineffectual  either  in  relieving 
thirst  or  in  diluting  the  contents  of  the  stomach  and  so  assisting  in  their 
expulsion.  Hot  water  is  better  than  cold,  and  drinks  should  not  be 
repeated  oftener  than  every  fifteen  minutes.  Ice,  for  the  purpose 
of  slaking  thirst,  as  well  as  ice-water,  should  be  banished  from  the  sick 
room.  It  does  nothing  toward  reducing  temperature  which  ice  applied 
externally  will  not  do.  If  it  momentarily  decreases  the  sensation  of 
thirst,  it  in  reality  increases  and  stimulates  it  by  causing  a  hyperemia  of 
the  mucous  membranes  of  the  mouth  and  throat. 

Sometimes  a  patient  will  appreciate  a  drink  of  hot  weak  tea,  the 
flavor  giving  a  satisfaction  which  does  not  exist  in  plain  water.  In 
the  same  way,  champagne  or  siphon  soda  may  be  used,  or  raisin  tea, 
or  a  drink  made  up  of  the  juice  of  i  lemon,  i  ounce  of  glycerin,  and  i  pint 
of  water,  or  equal  parts  lemon-juice  and  glycerin.  If  the  patient  has 
lost  blood,  or  is  stiU  oozing,  there  wiU  be  advantage  in  giving  dilute 
gelatin  solution,  with  lemon  added  for  flavor.  If  a  patient  complains 
of  thirst,  and  it  is  not  desired  to  give  water  by  mouth,  much  satisfaction 
will  be  afforded  by  allowing  the  patient  to  suck  the  end  of  a  towel  mois- 
tened in  water  or  to  chew  gum. 

Washing  of  the  mouth  is  always  appreciated  by  a  patient  after  anes- 
thesia. It  removes  the  disagreeable  sensation  of  dryness  and  stickiness, 
the  foul  taste  following  vomiting,  and  bits  of  vomitus  themselves.  If 
DobeU's  solution  is  used,  or  glycerin  and  rose-water  equal  parts,  there 
is  substituted  a  pleasant  taste  and  an  agreeable  sense  of  cleanliness  and 
coolness.  Patients  are  rarely  too  weak  to  rinse  out  their  mouths.  If 
this  condition  arises,  the  nurse  can  wash  out  the  mouth  and  scrub  the 
furred  tongue  with  her  forefinger  wrapped  in  absorbent  cotton  and  dipped 
in  the  solution.  For  this  purpose  glycerin  with  a  few  drops  of  lemon- 
juice  added  is  good. 

Proctoclysis. — In  serious  conditions,  where  water  in  sufficient 
amount  by  mouth  is  impracticable,  the  simplest  method  for  its  adminis- 
tration is  by  means  of  enema.  If  the  need  is  anticipated  before  the 
operation  is  over,  an  enema  of  normal  saline  solution  (a  teaspoonful  of 
salt  to  a  pint  of  warm  water)  may  be  given  while  the  patient  is  still 
under  the  influence  of  the  anesthetic,  otherwise  the  enema  may  be  started 
as  soon  as  the  patient  has  been  put  to  bed,  and  a  quart  may  be  given 
and  repeated  in  t^vo  hours  if  necessary.  As  in  giving  fluids  by  rectum 
in  bulk  there  is  a  likelihood  of  a  considerable  proportion  not  being  re- 
tained, especially  with  a  patient  not  fully  reco\-ered  from  the  anesthetic 
or  weakened  by  hemorrhage  or  shock,  it  is  often  of  advantage  to  admin- 


PROCTOCLYSIS 


43 


ister  saline  solution  by  the  drop  or  Murphy  method.^  For  this  purpose 
the  fountain  syringe  is  hung  at  a  moderate  distance  above  the  bed  (page 
470),  in  a  position  where  it  or  the  tube  will  not  be  disturbed  by  the  patient. 
On  the  tube  a  damp  or  hemostat  is  adjusted,  so  that  the  water  comes 
away  drop  by  drop  at  the  rate  of  about  a  drop  a  second.  To  the  end 
of  the  tube  is  attached  a  small-caliber  soft-rubber  catheter,  and  this  is 
introduced  6  inches  into  the  rectum.  The  water  in  the  syringe  should 
be  hot,  so  as  to  allow  for  cooling  in  the  tube. 

Several  forms  of  special  apparatus  have  been  recently  devised  to 
keep  the  supply-tank  warm  during  the  long  administration.  Thus,  G.  J. 
Saxon^  describes  an  apparatus  which  maintains  the  temperature  of  the 
solution  to  be  given  by  rectum,  and  which  controls  the  flow  in  a  manner 
which  will  not  interfere  with  the  quick  passage  of  flatus  or  the  sudden 
expulsion  of  salt  solution  back 
through  the  tube 


The  fluid 
enters  the  rectum  at  a  tem- 
perature ranging  from  100°  to 
115°  F.  He  uses  a  copper 
bucket  with  legs,  handle,  and 
lid;  inside  of  this  is  placed  a 
glass  percolator,  to  be  used  as 
a  reservoir,  and  about  this  is 
placed  a  warming  fluid  (Fig. 
14).  The  technique  in  the 
application  of  the  Murphy 
treatment  is  so  perfected  by 
Dr.  Saxon's  apparatus  that  the 
solution  can  be  kept  at  a  tem- 
perature of  from  105°  to  ii5°F. 

without  any  interference  for  a  period  of  two  hours  or  longer;  it  is  easily 
renewed  for  prolonged  application;  rapidity  of  flow  is  under  accurate 
control ;  a  thermometer  interspersed  near  distal  end  permits  easy  reading 
of  temperature  near  the  exit. 

Another  form  is  that  of  D.  N.  Eisendrath,^  who  says:  "One  of  the 
most  difficult  problems  in  connection  with  the  use  of  salt  solution  per 
rectum  has  been  to  maintain  it  at  a  constant  temperature.  The  usual 
custom  is  to  surround  a  glass  percolator  with  hot-water  bags,  which 
later  must  be  refilled  frequently.  I  have  devised  a  simple  and  in- 
expensive apparatus,  by  which  a  constant  temperature  can  be  main- 

^  Jour.  Am.  Med.  Assoc,  1909,  Hi,  1248.  ^  Ann.  Surg.,  1909,  xlix,  404. 

^  Jour.  Am.  Med.  Assoc,  1908,  li,  406. 


Fig.  14. — Saxon's  Apparatus  for  Murphy  Method. 


44 


THIRST,    ITS    SIGNIFICANCE   AND   RELIEF 


tained,  either  by  the  use  of  electricity,  an  alcohol  lamp,  or  small 
Bunsen  burner.  It  is  designed  on  the  plan  of  the  filters  which  are  used 
in  bacteriologic  laboratories  for  filtering  agar-agar.  It  is  made  of  tin,  and 
consists  of  a  double-walled  water-jacket  (c)  mounted  on  legs  8  inches 
in  height.  The  space  within  the  jacket  is  conical,  and  just  large  enough 
to  hold  a  glass  percolator  with  a  capacity  of  i  quart. 

"Rubber  tubing  is  attached'  to  the  lower  end  of  the  percolator  and  con- 
nected with  an  ordinary  rectal  tube.  The  flow  is  regulated  by  a  special 
screw-cock  in  such  a  manner  that  a  drop  per  second  escapes  into  the 
rectum.  It  is  possible  for  the  patient  to  absorb  lo  pints  in  twenty-four 
hours.  The  lower  level  of  the  water  should  be  8  inches  higher  than  the 
bed,  so  as  to  permit  a  continuous  flow.     If  electricity  is  employed  as  a 


Fig.  IS- — Eisendrath's  Apparatus  for  Continuous  Rectal  Saline  Instillation. 
a.  Thermophore;  b,  percolator;  c,  water-jacket;  d,  projection  of  c  for  gas  heating. 


source  of  heat,  a  special  thermophore  {a)  is  used,  which  is  inserted  directly 
into  the  percolator  {h),  and  maintains  a  constant  temperature  of  120°  F., 
so  that,  allowing  for  an  unavoidable  loss  of  heat,  the  salt  solution  flows 
into  the  rectum  at  a  temperature  of  95°  to  100°  F.  The  cut  incorrectly 
shows  the  thermophore  inserted  into  the  outer  chamber.  If  gas  or  an 
alcohol  lamp  is  employed  (as  might  be  necessary  in  private  residences) , 
the  water  in  the  outer  chamber  (c)  is  heated  at  the  projection  {d).''^ 

^  Other  references  on  this  subject  are:  S.  E.  Newman,  Jour.  Am.  Med.  Assoc., 
1909,  lii,  1250,  Continuous  Enteroclysis. 

B.  B.  Wechsler,  Jour.  Am.  Med.  Assoc,  1909,  lii,  1251,  An  Apparatus  to  Keep 
Enteroclysis  Solutions  Hot. 

J.  B.  Murphy,  Jour.  Am.  Med.  Assoc,  1909,  lii,  1248,  Proctoclysis  in  the  Treatment 


SALINE    INFUSION 


45 


Some  surgeons  make  it  a  practice  in  celiotomies,  when  the  patient  is 
in  a  serious  condition  from  shock,  or  when  the  operation  is  being  done  on 
a  patient  in  extremis,  say,  from  intussusception  or  strangulated  hernia, 
to  leave  a  quart  or  so  of  hot  normal  salt  solution  in  the  peritoneal  cavity 
on  sewing  up.  This  maneuver  takes  no  time  and  sometimes  acts 
effectually  in  forestalling  shock  and  thirst.  In  localized  septic  conditions, 
as  appendix  abscess,  pyosalpinx,  or  localized  peritonitis,  its  employment 
is,  of  course,  contra-indicated,  as  the  fluid  tends  to  disseminate  the  in- 
fection. In  diffuse  peritonitis,  where  the  infection  is  already  widespread, 
and  in  such  conditions  as  bullet  wounds  of  the  intestine  or  rupture  of  a 


Fig.  i6. — Subcutaneous  Saline  Infusion. 
Needle  under  the  breast,  reservoir  vessel  held  aloft,  dressing  material  on  table. 

gastric  or  duodenal  ulcer,  operated  on  immediately,  where  material 
which  is  presumably  strongly  infective  is  spread  about  generally  through 
the  abdomen,  the  water  which  is  allowed  to  remain  after  washing  out 
the  peritoneal  cavity  acts  beneficially  in  diluting  the  infective  material 
and  in  exciting  a  secretion  of  bactericidal  serum  from  the  peritoneum. 

Saline  Infusion.— Finally,  the  method  for  supplying  fluid  to  the 
body,  which,  of  all  the  artificial  means,  is  probably  the  most  commonly 

of  Peritonitis.  Shows  apparatus  for  maintaining  the  heat  of  the  solution  by  electricity, 
gas,  or  alcohol  flame. 

Kemp,  New  York.  Med.  Jour.,  1909,  xl,  298.,  A  New  Container  for  the  Preservation 
of  a  Constant  Temperature  of  Saline  Solution  for  Rectal  Irrigation  or  Infusion.  An 
application  of  the  vacuum  bottle  to  proctoclysis,  entcroclysis,  hypodermoclysis,  and 
infusion. 


46  THIRST,   ITS   SIGNIFICANCE  AND   RELIEF 

employed,  is  the  administering  of  sterile  salt  solution  by  subcutaneous 
injection.  For  this  purpose  a  thoracentesis  or  salt  infusion  needle  of 
medium  size  is  used.  It  should  be  sterile,  and  attached  to  a  sterile 
rubber  tube,  which  in  turn  may  be  connected  with  the  nozzle  of  the  con- 
tainer of  the  salt  solution.  In  the  technique  of  administering  a  subcutane- 
ous injection  all  care  with  regard  to  asepsis  of  the  operator,  the  field, 
the  instruments,  and  the  solution  should  be  exercised  in  order  that  the 
danger  of  submammary  or  other  abscess  be  reduced  to  a  minimum. 
The  field  usually  chosen  is  the  breast,  the  injection  is  made  (with  the 
needle  full  of  water  and  the  tube  pinched)  in  the  outer  lower  quadrant, 
upward  and  inward  under  the  mammary  tissue,  or  upward  under  the 
pectorals  and  into  the  axilla.  Sometimes  the  injection  is  made  into  the 
inner  aspect  of  the  thigh  or  in  the  loin. 

The  needle  should  be  inserted  its  full  length,  and  as  the  tissue  begins 
to  bulge  with  fluid,  the  unengaged  hand  of  the  operator,  anointed  with 
sterile  oil,  should  massage  the  parts,  to  assist  the  tissues  in  taking  up  the 
solution.  As  the  fluid  runs  in  and  the  parts  become  white  and  tense, 
the  needle  may  be  gradually  withdrawn,  or  its  point  shifted  from  time  to 
time  in  various  directions,  to  open  up  new  avenues  of  absorption.  A 
quart  of  fluid  is  the  ordinary  limit  in  one  place.  If  more  is  to  be  given, 
it  is  better  to  give  a  quart  under  each  breast.  Undoubtedly  in  men 
the  best  site  of  injection  is  upward  under  the  pectorals,  for  here  there 
is  all  the  loose. tissue  of  the  axillary  space  to  take  up  the  fluid  rapidly. 
After  the  injection,  the  needle  is  quickly  withdrawn,  a  finger  placed 
over  the  puncture  to  prevent  oozing,  the  surrounding  skin  wiped  dry, 
and  a  small  wad  of  sterile  absorbent  cotton  is  applied  and  held  in  place 
by  collodion.  The  dangers  to  be  avoided,  after  sepsis,  are  puncture  of 
a  vein,  injection  of  air,  puncture  of  the  pleura. 


CHAPTER   IV 

PAIN  AND  SLEEP 

The  amount  of  postoperative  pain  seems  to  bear  no  relation  to  the 
seriousness  of  the  operation.  Some  patients  after  minor  procedures 
will  suffer  agony,  while  others,  who  have  endured  a  serious  or  pro- 
tracted abdominal  operation,  make  no  complaint  except  perhaps  of  a 
backache.  The  personal  element  seems  of  much  importance  here,  for 
the  better  the  mental  control,  or  the  deeper  the  faith  in  the  surgeon, 
the  less  is  the  likelihood  of  the  patient's  magnifying  discomfort  into 
pain. 

If  in  a  celiotomy  there  have  been  found  extensive  adhesions,  or  if  the 
occasion  has  made  necessary  much  handling  of  the  intestines,  pain  is 
pretty  sure  to  follow.  The  most  common  cause  of  pain  in  abdominal 
cases  is  distention  of  the  bowel.  From  one  cause  or  another  there  is 
induced  a  paresis  of  the  intestines,  then  distention  with  gas,  and  the 
patient,  unable  to  pass  it  himself,  suffers  from  colicky  pains,  which 
are  the  more  trying  because  the  relief  ordinarily  afforded  by  pressure  and 
movement  in  bed  is  not  at  his  disposal.  In  this  case  the  relief  of  the 
distention  by  measures  to  be  discussed  later  is  to  be  sought. 

Another  cause  of  postoperative  pain  is  pressure  from  packing  or 
from  drainage,  either  by  gauze  wicks  or  glass  or  rubber  tubing.  Wounds 
are  packed  for  different  purposes,  such  as  to  control  hemorrhage,  or  to 
absorb  pus  or  serous  fluid.  To  accomplish  these  purposes  it  may  be 
essential  that  the  packing  should  be  tight,  and  any  pain  which  results 
must  accordingly  be  endured  if  it  cannot  be  relieved  by  some  other  means. 
The  most  that  can  be  done  is  to  make  certain  that  the  packing  is  rightly 
placed  and  is  no  tighter  than  is  necessary  to  serve  its  purpose.  It 
usually  becomes  unnecessary  after  twenty-four  hours.  Relief  can  be 
obtained  at  the  time  of  redressing.  Gauze  wicks  rarely  exert  enough 
pressure  to  cause  trouble.  Rubber  tubing,  however,  and  glass  tubing 
may  exert  considerable  pressure  on  the  intestine  or  rectum,  and,  if 
disturbed  by  the  restlessness  of  the  patient,  may  even  slip  through  the 
wound  into  the  abdomen.  In  placing  rubber  or  glass  drainage-tubes  one 
should  be  sure  that  their  edges  are  well  protected,  that  they  are  so  placed 
that  they  exert  no  pressure  upon  the  gut,  and  that  they  are  so  long  that 
there  is  no  danger  of  their  slipping  into  the  abdominal  cavity.     Until  the 

47 


48  PAIN   AND   SLEEP 

proper  time  for  their  removal  any  pain  which  they  cause  must  be  treated 
by  means  of  morphin. 

Gibbon^  says:  "Pain  varies  greatly  according  to  the  site  of  oper- 
ation and  the  individual  disposition.  Abdominal  operation  produces 
more  pain  than  others  because  of  the  aggravation  and  discomfort 
caused  by  the  movement  of  the  diaphragm,  especially  such  excessive 
actions  of  this  muscle  as  take  place  in  retching  and  coughing.  It  is  a 
good  rule  always  to  administer  a  hypodermic  of  morphin  and  atropin 
before  the  patient  has  recovered  consciousness.  The  patient  passes 
from  the  sleep  of  the  anesthesia  to  the  morphin  sleep,  gets  comfortably 
over  the  most  distressing  hours  after  operation,  and  never  knows  the 
morphin  has  been  given.  It  is  seldom  that  a  second  dose  is  necessary, 
and  postoperative  vomiting  is  infrequent." 

Pain  developing  some  hours  after  operation  is  not  to  be  dismissed 
with  the  administration  of  an  anodyne,  but  its  cause  should  be  carefully 
sought  and  removed.  Often  a  simple  change  of  posture,  the  cutting 
of  a  tight  bandage,  the  removal  of  pressure  on  some  bony  prominence, 
straightening  out  the  clothing,  and  such  little  attentions  will  give  relief. 
A  safety-pin  passed  through  the  patient's  skin  in  fixing  the  bandage  may 
cause  the  trouble. 

Another  common  cause  of  the  complaint  of  pain  is  splints.  As 
usually  constructed,  splints  are  rigid  and  unyielding.  Whenever  they 
are  applied  to  unconscious  patients,  one  can  never  be  sure,  no  matter 
how  generously  they  are  padded  and  how  carefuUy  they  are  put  on,  that 
some  point  is  not  unduly  pressed  upon.  As  soon  as  consciousness  is 
regained,  every  splint  should  be  subjected  to  detailed  inspection  and 
careful  readjustment.  No  complaint  on  the  part  of  the  patient  referred 
to  the  splinted  limb,  however  trivial  it  may  seem,  is  to  be  neglected; 
particularly  is  it  important  to  see  that  the  circulation  and  the  sensation 
of  the  part  is  not  interfered  with;  coldness,  blueness,  edema,  or  numbness 
of  the  finger-tips,  for  instance,  must  be  instantly  relieved  by  loosening 
the  splints.  In  applying  splints,  one  must  remember  that  a  certain 
degree  of  swelling  follows  every  trauma,  and  that  due  allowance  must  be 
made  for  this.  Plaster  bandages  make  the  best-fitting  and  most  effec- 
tive splints,  but  they  can  easily  cause  a  great  deal  of  discomfort  and 
serious  damage  on  account  of  their  unyielding  nature  and  their  intensive 
pressure  as  swelling  takes  place.  Instant  relief  is  obtained  and  all 
danger  averted,  w^ithout  sacrificing  efficient  fixation,  simply  by  splitting 
the  bandage  itself  full  length  down  one  or  both  sides.  Operations  in- 
volving bones  and  joints  are  peculiarly  liable  to  give  rise  to  pain;  still, 

^  Postoperative  Treatment,  Ann.  Surg.,  1907,  xhi,  298. 


CAUSES   OF   PAIN  49 

morphin  should  never  be  given  to  a  patient  wearing  a  splint  until  it  is 
certain  that  the  splint  itself  is  not  at  fault. 

If  properly  applied,  the  dressing  itself  is  rarely  a  source  of  pain  or 
discomfort  for  the  lirst  twenty-four  hours.  However,  there  are  two  evils 
which  may  be  due  to  the  dressing  in  this  early  period,  therefore  it  'is 
unwise  not  to  investigate  complaints.  The  dressing  may  have  slipped, 
owing  to  its  insecure  retention  or  to  the  patient's  movements,  leaving  the 
wound  partially  or  wholly  uncovered;  or  the  sharp  end  of  a  suture  may 
be  pricking  the  skin.  Relief  is  easily  obtained.  After  twenty-four  hours 
the  dressing  becomes  hard  and  caked  from  the  dried  secretions.  This 
serves  as  a  splint  and  rarely  causes  distress.  The  removal  of  the  dried 
gauze  is  all  that  is  necessary  if  there  is  real  discomfort. 

It  is  only  a  poorly  applied  bandage  that  causes  pain.  A  bandage 
serves  two  purposes — it  keeps  the  dressing  in  place  and  gives  firm,  even 
pressure.  Several  layers  of  sheet  wadding  beneath  a  bandage  give  the 
whole  dressing  elasticity  and  help  to  distribute  the  pressure  evenly. 
A  bulky  dressing  gives  the  most  comfort.  Every  bandage  should 
be  applied  from  an  extremity  toward  tlie  trunk,  steadily  lessening  the 
pressure  while  advancing.  Too  tight  a  bandage  causes  pain  from  con- 
gestion; too  loose  a  bandage  causes  discomfort  and  even  pain  by  allow- 
ing the  dressing  to  slip  about.  One  should  watch  particularly  the  limits 
of  the  bandage,  for  it  is  here  that  painful  chafing  readily  occurs. 

Every  wound  is  surrounded  by  localized  muscular  spasm.  This 
is  nature's  method  of  maintaining  the  part  at  rest.  It  is  most  apparent 
in  fractures.  If  the  muscles  become  tired  and  relax,  pain  then  occurs 
from  the  fatigued  muscles  and  from  the  wound,  which  is  no  longer  kept 
at  rest;  spasm  then  becomes  noticeable  because  it  is  painful.  The  way 
to  prevent  painful  spasm,  or  to  treat  it  if  present,  is  to  inmiobilize  the 
wounded  part.  A  firmly  applied  bandage  is  often  sufficient.  If  the 
wound  is  near  a  joint,  a  properly  fitted  splint  to  fix  the  joint  is  essential. 
Wounds  of  the  trunk  are  readily  immobilized  by  adhesive  plaster  strap- 
ping or  tight  swathes. 

Pain  from  stitches  is  due — (i)  to  tying  the  suture  too  tightly,  thus 
putting  the  parts  under  too  great  tension;  (2)  to  imperfect  immobiliza- 
tion of  the  wound;  and  (3)  to  sharp  ends  of  the  sutures  pricking  the  skin. 
The  last  has  already  been  spoken  of  and  its  treatment  indicated.  If  the 
wound  is  immobilized,  as  described  above,  the  stitches  in  themselves 
cause  very  little  discomfort.  .  Even  if  the  sutures  have  been  too  tightly 
tied,  one  dislikes  to  cut  them  at  the  risk  of  having  the  wound  gape  open. 
Relief  can  be  obtained  by  the  use  of  adhesive  straps,  so  applied  that  the 
tension  on  the  stitches  is  lessened.     The  method  is  as  follows:  Cut  two 


50 


PAIN   AND   SLEEP 


pieces  of  adhesive  plaster,  shaped  as  in  Fig.  17,  and  fasten  the  broad  ends, 
a,  a,  on  opposite  sides  of,  and  at  some  distance  from,  the  wound,  so 
that  the  narrow  ends  cross  the  womid,  the  tongue,  h,  lying  in  the  space 
c.  While  an  assistant  presses  the  sides  of  the  wound  together,  the 
narrow  ends  are  drawn  taut  and  stuck  fast  to  the  skin.  If  the  tension  is 
still  painful,  the  stitches  are  very  probably  cutting  their  way  out.  Only 
when  this  is  actually  seen  to  be  the  case  is  it  advisable  to  cut  the  sutures 
and  trust  to  the  strapping  to  hold  the  wound  together. 

Every  septic  process  is  accompanied  by  pain,  varying  all  the  way 
from  the  nagging  discomfort  of  a  furuncle  to  the  intense  throbbing, 
excruciating  pain  of  bone  infection.  Incision  and  drainage,  by  reducing 
tension,  generally  afford  immediate  relief  to  such  an  extent  that  opiates 
are  not  required.  If,  however,  sufhcient  relief  is  not  obtained  by  sat- 
isfactory incision  and  drainage,  it  is  far  better  to  give  morphin  than  to 
let  the  patient  lower  his  powers  of  resistance  through  suffering. 

Rest  and  sleep  are  not  compatible  with  pain.  As  rest  and  sleep  are 
requisite  elements  of  a  safe  and  speedy  convalescence,  they  should  be 


Fig.  17. 

encouraged  after  operation  by  all  safe  means.  Most  often  the  occur- 
rence of  pain  can  be  estimated  in  advance,  and,  if  no  contra-indication 
■exists,  the  patient's  comfort  can  be  assured,  after  setting  or  wiring 
the  fracture,  after  amputation,  after  a  dilatation  and  curettage,  by 
injecting  subcutaneously  a  dose  of  morphin  before  the  patient  has 
recovered  from  the  anesthetic.  After  operations  about  the  anus  or 
male  urethra  morphin  may  be  administered  similarly  in  the  form  of 
suppositories.  Giving  morphin  in  this  fashion  before  coming  out  of 
ether  often  works  strikingly;  the  patient  awakens  from  a  quiet  sleep, 
two  or  more  hours  after  the  operation  is  over,  with  a  sense  of  well-being 
and  no  memory  of  the  discomforts  of  nausea  or  vomiting.  As  many 
patients  dread  the  postoperative  pain  more  than  the  idea  of  the  opera- 
tion itself,  this  relief  will  assure  the  surgeon  of  their  gratitude. 

In  operations  upon  the  abdomen  surgeons  are  of  two  minds  as  to 
the  propriety  of  employing  morphin  at  all.  Lawson  Tait  was  the  first 
to  argue  strongly  against  its  use  after  celiotomies,  on  account  of  its  effect 
in  decreasing  intestinal  peristalsis  and  its  action,  accordingly,  in  favoring 
the  production  of  distention.     It  is  known  that  distention  and  intestinal 


RELIEF    OF    PAIN    '  5 1 

paresis  favor  the  occurrence  of  peritonitis,  especially  after  operations 
involving  infected  matter,  such  as  for  salpingitis  and  appendicitis. 
Over  against  these  theoretic  considerations  other  men  have  placed  the 
comfort  and  quiet  which  come  from  morphin  properly  used,  and  have 
favored  the  use  of  morphin  after  celiotomies  as  a  routine.  Perhaps  the 
safest  rule  to  follow  in  this  regard  is  to  use  morphin  after  celiotomies 
where  much  pain  is  anticipated,  provided  there  has  been  no  infected 
material  let  loose  into  the  abdomen.  In  cases  of  peritonitis,  or  where 
peritonitis  is  imminent,  it  will  be  wise  not  to  allow  one's  self  to  use 
morphin  until  the  bowels  have  moved  for  the  first  time  after  operation. 

Sometimes  it  will  be  found  that  heat  in  the  form  of  fomentations, 
stupes,  or  poultices,  applied  locally,  will  be  efl&cacious  in  relieving  pain 


k^ 


Fig.  i8. — Technique  of  Hypodermic  Injection. 

The  skin  is  pinched  up  in  a  fold  into  which  the  needle  is  inserted  at  right  angles  to  the  sldn.     The  injection  is 

thus  truly  subcutaneous  and  not  intracutaneous. 

of  local  origin.  In  the  same  way,  cold  may  be  employed  advantageously, 
especially  after  operations  upon  joints.  As  the  weight  of  a  hea\y  ice-bag 
or  hot-water  bag  might  in  itself  cause  considerable  pain,  it  is  well  to  have 
such  a  bag  slung  from  a  cradle,  or  in  some  other  way  suspended  s6  as  to 
take  the  weight  off  the  wound.  It  will  easily  be  found  that  if  pain  is 
relieved  by  one  or  the  other  of  the  methods  which  we  have  suggested, 
sleep  will  naturally  follow.  When  it  becomes  necessary  to  resort  to 
drugs,  morphin  is  by  far  the  most  reliable  where  no  contra-indication 
exists.  Sometimes  trional,  paraldehyd,  hyoscin,  or  codein  will  be  found 
to  work  equally  satisfactorily.  If  the  patient  is  kept  awake  by  pure 
nerv'ousness,  rectal  enemas  of  sodium  bromid  (gr.  1  to  Ixxx)  or  chloral- 
amid  (gr.  xxx)  act  advantageously.  By  whatever  means  effected,  sleep 
must  be  induced  as  essential  to  the  patient's  well-being. 


CHAPTER   V 

PULSE,  TEMPERATURE,  AND  RESPIRATION 

The  temperature  chart  may  be  considered  the  barometer  of  the 
patient's  condition.  It  is  one  of  the  few  means  of  accurate  observation 
which  we  have  at  our  disposal,  and  should  never  be  neglected.  Some 
surgeons  of  wide  experience  will  sometimes  studiously  ignore  the  chart 
and  pass  their  judgment  of  a  patient's  condition  upon  his  general  aspect, 
his  posture,  the  appearance  of  his  tongue,  and  all  these  aided  by  intuition. 
Their  deductions  may  often  appear  brilliant,  but  their  example  is  a 
dangerous  one  for  the  younger  man  to  follow. 

When  one  has  studied  many  charts  representing  the  same  condition, 
he  is  usually  able  to  prognosticate  with  some  degree  of  accuracy  in  the 
case  of  any  individual  patient.  If  one  considers  the  pulse  alone,  how- 
ever, or  the  temperature  alone,  he  is  likely  to  be  led  astray.  The  firmest 
conclusions  can  be  drawn  only  from  a  study  of  the  pulse  and  the  tem- 
perature and  the  respirations  and  their  relation  to  each  other.  For 
instance,  a  falling  temperature  in  itself  is  usually  of  good  omen;  when 
combined  with  a  rising  pulse,  it  may  mean  serious  trouble.  A  surgeon 
may  argue  that  a  patient  cannot  be  badly  off  when  his  pulse  and  tem- 
perature are  both  normal,  but  a  normal  pulse  and  temperature  after  a 
celiotomy,  combined  with  an  increased  respiratory  rate,  is  very  likely  to 
mean  peritonitis. 

PULSE 

The  most  importance  is  usually,  and  properly,  placed  upon  the  ob- 
servation of  the  pulse.  Although  the  rate  is  the  only  quality  which  is 
usually  recorded  upon  the  chart,  the  surgeon  should  also  take  into  con- 
sideration the  rhythm,  volume,  and  tension.  Moreover,  if  he  would  save 
himself  the  possibility  of  some  needless  anxiety  later,  the  surgeon  should 
have  become  familiar  with  any  peculiarity  of  the  patient's  pulse  before 
operation,  as,  for  instance,  the  irregular  rhythm  and  the  constantly  in- 
creased or  diminished  pulse-rate  which  one  sometimes  comes  across  in 
otherwise  normal  young  individuals,  which  apparently  have  no  pathologic 
significance.  In  this  study  of  the  pulse,  from  the. point  of  view  of  the 
surgeon,  we  will  confine  ourselves  to  a  consideration  of  the  variations 
dependent  upon  and  following  surgical  procedure,  it  being  understood 

52 


PULSE 


53 


that  cardiac  lesions,  angina,  and  arteriosclerosis  have  been  ruled  out  by 
a  previous  examination,  or  that  due  allowance  is  made  when  they  exist. 

The  normal  pulse-rate  may  be  considered  to  be  72  beats  per  minute. 
The  excitement  preceding  an  operation  and  attending  the  administra- 
tion of  the  anesthetic  usually  increases  this  rate,  except  in  the  most 
phlegmatic,  about  20  beats.  If  the  operation  is  short  and  involves 
little  loss  of  blood,  and  the  anesthesia  is  well  conducted,  the  pulse  recovers 
somewhat  from  this  preliminary  rise  as  soon  as  the  patient  has  cleared 
himself  of  mucus.  During  the  recovery  the  rate  will  probably  drop  still 
farther  and  its  normal  quality  will  be  restored,  to  continue  normal,  un- 
less complications  arise,  throughout  the  convalescence.  After  any  pro- 
longed or  serious  operation,  or  one  attended  by  a  loss  of  blood,  the 
patient  may  be  put  to  bed  with  the  pulse-rate  increased  an3rwhere  from 
25  to  40  beats. 

Most  celiotomies  show  a  rise  of  10  to  20  beats  after  the  patient  has 
fully  recovered  from  ether.  This  rate  gradually  drops  off,  unless  com- 
plications arise,  to  reach  normal  on  the  second  or  third  day.  If  the 
pulse-rate  rises  suddenly  on  the  third  or  fourth  day,  we  have  to  con- 
sider the  onset  of  peritonitis  or  some  intercurrent  affection,  as  bron- 
chitis, pneumonia,  la  grippe,  tonsillitis,  malaria,  or  an  acute  exanthem. 
Distention  alone  is  apt  to  send  up  the  pulse-rate,  and  is  likely,  also,  to 
cause  it  to  become  irregular.  If  the  pulse  goes  up  for  the  first  time  at 
the  end  of  a  week  after  operation,  there  is  likelihood  of  a  stitch-abscess 
or  pelvic  abscess.  A  sudden  and  rapid  increase  in  pulse-rate  at  any 
time,  coupled  with  dyspnea,  usually  means  pulmonary  embolism. 

After  hemorrhage  the  increase  in  frequency  will  depend  not  so  much 
upon  the  amount  itself,  as  upon  the  rapidity  with  which  a  considerable 
amount  is  lost;  for  instance,  the  loss  of  blood  during  4  or  5  beats  from  a 
medium-sized  trunk  seems  to  send  up  the  pulse-rate  much  more  effec- 
tually than  the  loss  of  the  same'  amount  of  blood  from  a  small  vessel. 
It  may  be  considered  that  in  the  former  case  the  heart  is  wearing  itself 
out  by  pumping  against  a  suddenly  and  enormously  decreased  peripheral 
resistance — to  be  compared  to  a  fighter  who  puts  his  whole  force  in  a 
blow,  fails  to  meet  his  object,  and  exerts  his  energy  on  empty  air.  Unless 
the  hemorrhage  is  checked,  the  rate  rapidly  and  progressively  rises,  the 
pulse  finally  becomes  uncountable,  and  the  patient  dies. 

Intense  pain  will  frequently  send  up  the  pulse-rate  from  10  to  20 
beats,  and  sometimes  in  nervous  women  the  pulse  will  suddenly  increase 
to  120  or  over  without  apparent  cause.  In  the  former  case  a  subcutan- 
eous injection  of  morphin  will  relieve  the  pain  and  restore  the  pulse  to 
normal.     The  nervous  crises  are  probably  related  to  pseudo-anginal 


54 


PULSE,    TEMPERATURE,    AND    RESPIRATION 


attacks  which  the  patient  has  had  when  in  her  normal  state.     The  use  of 
bromids  by  rectum  is  indicated  as  soon  as  the  diagnosis  is  made  sure. 

Rarely  the  pulse-rate  will  fall  below  normal.  The  slow  full  pulse 
is  the  accompaniment  of  increased  intracranial  pressure  from  hemorrhage, 
clot,  abscess,  or  tumor.  The  pulse-rate  is  usually  restored  to  normal 
within  a  few  seconds  after  decompression  has  been  practised.  Elderly 
persons  with  good  heart  muscle  and  more  or  less  thickened  vessels 
are  apt  to  exhibit  ordinarily  a  slow  pulse.     The  pulse  is  commonly 


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Fig.    19. — Normal  Reaction  After  Aseptic  Operation. 


slowed  during  convalescence  from  erysipelas,  pneumonia,  or  typhoid. 
If  the  chart  records  a  slow  pulse  where  it  is  not  readily  accounted  for, 
one  must  not  be  satisfied  until  he  listens  at  the  apex,  for,  in  conditions 
of  marked  debility,  it  will  sometimes  be  found  that,  on  account  of  the 
weakness  of  the  stimuli,  the  arterial  contraction-wave  expends  itself 
before  it  reaches  the  peripheral  arteries,  and  the  radial  pulse  records 
only  every  second  or  third  beat — thus  an  entry  of  60  on  the  record  may 
have  to  be  corrected  to  120. 

The  pulse  may  be  irregular  in  force  and  rhythm.     If  irregular  in 


PULSE 


55 


rhythm  alone,  and  of  well-sustained  force,  and  the  radial  pulse  registers 
every  contraction  of  the  heart,  the  condition  is  apt  to  represent  a  tem- 
porary vasomotor  derangement,  such  as  may  occur  in  persons  of  a  high- 
strung  or  hysteric  disposition.  In  other  words,  the  heart  (from  excite- 
ment) is  skipping  an  occasional  beat.  Such  a  condition,  other  things 
being  favorable,  is  sure  to  disappear  as  soon  as  the  patient  is  restored  to 
her  normal  state  of  nervous  equilibrium. 


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Postoperative  rise  in  temperature  and  pulse  simulating  sepsis,  but  due,  in  fact,  to  absorption  from  lacerated 

soft  parts.     Primary  healing. 


If,  on  the  other  hand,  the  irregularity  of  the  pulse  means  that  a  certain 
proportion  of  the  cardiac  contractions  are  lost  before  reaching  the  periph- 
eral arteries — even  if  the  cardiac  rhythm  itself  is  normal — or  if  irreg- 
ularity in  the  force  of  the  beat  exists,  or  if  the  pulse  is  irregular  both 
in  force  and  in  rhythm,  we  have  a  condition  of  the  gravest  significance, 
which  can  result  only  from  a  played-out,  overworked  heart-muscle. 
A  pulse  may  be  ever  so  weak  or  so  rapid,  but  so  long  as  it  is  regular  in 
force  and  rhythm  there  is  hope;  the  heart  in  such  a  case  preserves  its 
power  to  recuperate,  to  respond  to  stimulation  and  the  treatment  of  the 


56 


PULSE,    TEMPERATURE,    AND    RESPIRATION 


underlying  condition.  If,  now,  such  a  pulse  suddenly  becomes  irregular 
in  force  and  rhythm,  it  may  be  considered  that  the  nervous  and  muscular 
mechanism  of  the  heart  are  wearing  themselves  out  under  the  strain — that 
is  to  say,  that  the  heart  is  going  to  pieces. 

Irregular  pulse  occurs  in  shock,  hemorrhage,  and  overwhelming 
septic  intoxication  or  other  forms  of  toxemia,  such  as  thyrotoxicosis. 

The  volume  of   the  pulse  represents  the  quantity  of  blood  which 


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On  the  eighth  day  drainage  became  inetSdent,  and  a  week  later  a  second  operation  was  done,  after  which 
temperature,  pulse,  and  respiration  again  fell  to  normal. 


passes  under  one's  finger;  that  is,  the  arterial  content.  The  volume 
is  small  after  loss  of  blood  from  hemorrhage  and  in  conditions  where  the 
systemic  tissues  have  been  depleted  of  fluids  from  any  cause.  Thus, 
volume  decreases  with  increasing  hemorrhage  or  progressing  septic 
infections. 

Volume  is  closely  associated  with  tension.  Tension  represents  the 
pressure  within  the  artery;  it  expresses  the  degree  of  blood-pressure. 
It  is  measured  by  the  amount  of  compression  which  must  be  exerted  to 


PULSE 


57 


shut  off  the  transmission  of  the  pulse-wave.  A  rehable  appreciation 
of  arterial  pressure,  apart  from  volume,  can  be  acquired  only  after  con- 
siderable education  of  the  finger-tips.  In  making  the  observation  one 
must  not  be  led  astray  by  the  resistance  offered  by  the  thickened  walls 
in  arteriosclerosis.  The  use  of  blood-pressure  apparatus  generally 
after  operation  has  not  yet  demonstrated  its  necessity. 


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Rise  in   pulse  and   drop  in  temperature,  the  so-called  Gradual  development  of  distention  such  as 

"closing  of  the  jaws  of  death."  appears  in  a  diffuse  dry  peritonitis.     The  graphic 

record  in  no  way  suggests  the  actual  serious  condi- 
tion of  the  patient.  Old  people  react  less  mark- 
edly and  the  chart  is  of  less  value  as  a  criterion. 

Changes  in  volume  are  not  necessarily  related  to  changes  in  tension, 
but  the  two  qualities  are  often  characteristically  associated.  Thus, 
the  full  volume  and  high  tension  give  a  large,  hard,  bounding  pulse; 
with  the  low  tension,  a  full,  soft,  flabby  pulse;  low  volume  with  high 
tension  gives  the  small,  hard,  wiry,  cord-like  pulse,  and  with  low  tension 
the  flickering,  thready  pulse— all  of  which  have  important  clinical  sig- 
nificance. 


58 


PULSE,    TEMPERATURE,    AND   RESPIRATION 


TEMPERATURE 

Variations  in  temperature  may  be  considered  as  due  to  the  normal 
reaction  after  simple  aseptic  operations;  to  shock  after  prolonged  opera- 
tions or  those  attended  by  much  manipulation  of  the  abdominal  contents 
or  from  loss  of  blood;  to  septic  causes,  in  cases  febrile  at  the  time  of  oper- 
ation, or  those  developing  peritonitis,  or  pelvic  or  stitch-abscess;  and, 
finally,  to  accidental  and  intercurrent  conditions,  such  as  thrombosis, 
phlebitis,  or  pneumonia. 


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Rise  of  temperature  and  pulse  on  fourth  day,  aseptic 
absorption  from  retained  membranes. 


Fig.   2S.^Perineal   Prostatectomy  (weight  of 
prostate,  12  ounces). 
Marked    shock    shown    by    drop    in    tempera- 
ture and  rise  in  pulse;  then  temperature,  pulse,  and 
respirations  all  rise  till  the  end. 


Most  uncomplicated  aseptic  procedures  show  a  reactionary  rise  in 
temperature  which  reaches  its  maximum,  about  ioo°  F,,  twenty-four 
hours  after  operation,  and  strikes  normal  on  the  evening  of  the  second 
day  after  operation.  Sometimes  there  will  be  a  lesser  rebound  of  the 
temperature-curve  on  the  third  day  (Fig.  19).  The  pulse,  without  altering 
its  character,  accelerates  its  rate  simultaneously  with  and  in  proportion 


TEMPERATURE 


59 


to  the  rise  in  temperature,  usually  reaching  90°  or  100°  F.  In  children 
and  young  persons,  or  after  operations  on  bones,  or  about  the  anus,  the 
pyrexia  may  go  to  102°  F.  or  higher.  This  rise  in  temperature,  some- 
times called  aseptic  fever,  is  usually  to  be  expected,  and,  in  so  far  as  it 
represents  the  normal  reaction  in  persons  in  good  health  at  the  time  of 
the  operation,  it  is  a  good  sign  and  should  not  be  confused  with  sepsis. 
There  has  been  much  theorizing  concerning  the  mechanism  of  its  pro- 
duction.    It  may  intelligently  be  considered  as  due  to  absorption  of 


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Sustained  postoperative  reaction  in  a  neurotic  individual.    Typical  rise  of  temperature  on  first  day  out  of  bed. 

decomposition  products,  of  liberated  blood,  and  of  matters  set  free  by 
destruction  of  tissues. 

After  hemorrhage  or  in  shock  this  reaction  is  delayed.  The  first 
effect  on  the  temperature,  if  the  shock  is  considerable,  is  a  notable  fall. 
The  temperature  often  becomes  almost  immediately  normal  or  sub- 
normal, even  in  cases  febrile  before  operation,  and  the  pulse  rises 
sharply  to  130  or  more.  A  falling  temperature  with  rising  pulse  in  the 
early  hours  after  operation  must  always  make  us  fearful  of  collapse  and 


6o 


PULSE,    TEMPERATURE,    AND   RESPIRATION 


death.  If  the  patient  is  successful  in  combatting  the  condition,  a  late 
reaction  will  occur;  the  temperature  goes  up  to  a  degree  proportionate 
to  the  pulse,  and  then  pulse  and  temperature  gradually  subside,  to  reach 
normal  some  days  later. 

Sometimes  there  will  be  a  condition  of  continued  shock,  immediately 
following  operation,  which  lasts  for  twenty-four  to  forty-eight  hours 
before'  it  changes  for  better  or  worse.  Then  there  is  the  condition  of 
late  shock,  which  puts  in  a  rather  unexpected  appearance  twenty-four 


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Fig.  27. — Immediate  Drop  in  Temperature  and  Pulse  After  Relief  of  Tension  in  Sepsis. 


hours  after  the  operation,  the  patient  having  apparently  recovered 
normally  from  the  operation.  Often  there  is  a  low  fever,  about  101°  F., 
and  a  pulse  of  1 10,  where  no  symptoms  of  shock  are  apparent  in  cases  that 
have  endured  a  long  and  severe  operation.  This  condition  is  apt  to  be 
maintained  for  four  to  eight  days,  gradually  working  down  to  normal. 
It  may  be  taken  to  represent  not  so  much  shock  as  a  condition  of  ex- 
haustion and  a  poor  or  delayed  operative  reaction.  If  pulse  and  tem- 
perature are  approximately  normal,  or  if  the  normal  pulse-temperature 
ratio  is  maintained,  it  is  rarely  that  death  occurs  from  shock. 


TEMPERATURE 


6l 


The  onset  of  sepsis  is  usually  marked  by  an  immediate  rise  in  pulse 
and  temperature,  unless  the  patient  is  septic  at  the  time  of  operation. 
The  only  exception  to  this  rule  is  the  occurrence  of  sepsis  in  persons 
who  have  lost  their  powers  of  resistance  through  exhaustion;  a  patient 
may  die,  for  instance,  of  peritonitis,  with  a  normal  pulse  and  temperature. 
If  the  patient  is  febrile  from  retained  pus,  and  the  operation  consists 
in  liberating  this,  the  temperature  chart  is  apt  to  show  a  short,  sharp 


M,    C.  K.   G. 


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Rising  temperatare;  wound  inspected  on  the 
sixth  day,  stitch-abscess  found  and  relieved,  imme- 
diate drop  to  normal. 


Fig.  29. — Appendix  Abscess. 

Usual  drop  after  drainage,  sudden  rise  of  temper- 
ature on  the  fourth  day,  due  to  backing  up  of  pus, 
drop  to  normal  when  drainage  is  again  made  elhcient. 


reaction,  and  then  a  sure  and  progressive  decline  as  the  drainage  effec- 
tively acts  (Fig.  27).  If  the  patient's  temperature  is  about  normal, 
and  the  operation  discloses  an  abscess  and  some  pus  is  set  free  in  removal 
or  drainage,  there  will  be  the  regular  reactionary  rise  in  temperature, 
and  the  height  of  the  curve  will  be  maintained,  with  a  tendency  to  morning 
remissions,  until  the  system  has  successfully  combatted  the  infection. 
On  general  principles,  in  an  aseptic  operation  a  rise  in  temperature, 


62 


PULSE,    TEMPERATURE,    AND   RESPIRATION 


occurring  on  or  after  the  third  day  after  operation,  should  be  considered, 
until  proved  otherwise,  as  due  to  sepsis— from  infection  of  the  wound, 
peritonitis,  decomposition  of  retained  blood-clot.  In  a  septic  condition 
it  means  blocked  drainage,  residual  abscess,  peritonitis,  septicemia. 
A  late  rise — after  the  fifth  day — frequently  means  stitch-abscess  (Fig.  28). 
One  should  look  for  sepsis,  then,  whenever  the  reactionary  rise  in  tem- 


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Sharp  reaction  in  temi)erature  aad  pulse. 


Fig.    31. — General    Peritonitis 
OF  Subdiaphragmatic  Origin. 
Temperature  and  pulse  not  so 
significant    as    the    practically    con- 
tinuous rise  of  respirations. 


perature  fails  to  drop,  whenever  the  temperature  rises  on  the  third  day 
or  later. 

It  must  not  be  forgotten  that  complications  may  arise  during  con- 
valescence which  will  affect  the  appearance  of  the  chart  without  any 
respect  for  the  arbitrary  rules  which  we  have  laid  down  above.  Common 
among  these  are  tympanites,  menstruation,  tonsillitis,  erysipelas,  the 
acute  exanthems,  pneumonia.  Less  common,  but  not  to  be  overlooked 
when  other  causes  fail,  are  malaria,  la  grippe,  tapeworm,  phlebitis,  pyle- 


RESPIRATION  63 

phlebitis  (Fig.  30),  thrombosis,  and  embohsm.  When  the  temperature 
rises  from  these  so-to-speak  accidental  causes,  one  should  make  his 
diagnosis  with  extreme  care.     They  will  be  considered  in  detail  later. 

RESPIRATION 

The  record  of  the  respiratory  rate  is  apt  to  be  neglected.  A  good 
working  rule  is  to  take  the  respirations  whenever  the  patient  is  doing 
poorly,  or  whenever  the  diagnosis  of  his  condition  is  in  doubt. 

In  severe  hemorrhage  the  respiration  is  quickened  and  sighing,  the 
chin  is  elevated,  the  nostrils  dilated,  and  the  arms  thrown  over  the  head. 
In  pulmonary  embolism  the  respirations  are  rapid,  shallow,  and  gasping, 
the  mouth  is  held  open,  and  the  patient  tries  to  sit  up  in  bed. 

In  peritonitis  the  respirations  are  practically  always  increased  and 
may  run  up  to  48  per  minute  (Fig.  31),  The  abdomen  is  kept  tense  in 
an  effort  to  guard  and  "splint"  the  inflamed  and  acutely  painful  areas; 
there  is  no  longer  the  normal  rhythmic  rise  and  fall  of  the  abdominal 
wall.  In  advanced  cases  the  movements  of  the  diaphragm  even  are 
inhibited  and  the  respiration  becomes  entirely  thoracic. 

In  tympanites,  without  peritonitis,  these  same  phenomena  are  to  be 
noted  to  a  lesser  degree.  The  advantage  of  having  a  record  of  respira- 
tions in  case  there  is  question  of  the  onset  of  pneumonia  goes  without 
saying. 


CHAPTER   VI 

POSTOPERATIVE  HEMORRHAGE:    PRIMARY,   DELAYED, 
SECONDARY;  TRANSFUSION 

Postoperative  hemorrhage  may  be  defined  as  primary,  delayed, 
and  secondary. 

PRIMARY  HEMORRHAGE 

Primary  hemorrhage  is  that  form  which  comes  on  during  an  operation. 
The  indication  in  this  form  of  hemorrhage  is,  clearly,  to  find  the  bleeding 
point  and  secure  it.  The  after-treatment  may  be  considered  the  same 
as  that  for  shock.  This  condition  is  one  of  the  best  indications  for  the 
use  of  salt  solution  subcutaneously  and  the  employment  of  transfusion 
if  necessary.     These  are  dwelt  upon  in  detail  elsewhere. 

DELAYED  HEMORRHAGE  • 

Delayed  hemorrhage  may  be  taken  to  be  that  form  of  hemorrhage 
which  comes .  on  after  the  patient  has  recovered  from  the  anesthetic 
after  the  lapse  of  anywhere  from  a  few  hours  to  six  days. 

Causes. — (i)  A  wound  may  be  left  apparently  dry — on  account 
of  feeble  circulation  and  the  consequent  low  blood-pressure  no  bleeding 
may  be  apparent  from  some  smaller  cut  vessels  or  from  torn  tissues  or 
omentum.  Later,  after  the  operative  shock  passes  off,  blood-pressure 
increases  as  the  circulation  improves,  and  hemorrhage  results. 

(2)  Small  vessels  may  occlude  by  clot;  as  pressure  increases  or  the 
patient  moves  about,  the  clot  may  be  displaced  and  bleeding  ensues. 

(3)  Trifling  bleeding  may  not  be  noticed,  but  reliance  may  be  placed 
on  pressure  from  the  dressings.  A  small  vessel  may  be  cut  by  the  needle 
in  sewing  up.  This  forms  a  hematoma,  which  increases,  especially  in 
soft  tissues,  as  about  the  scrotum  and  lower  abdomen,  by  stripping  up 
skin  or  fascia. 

(4)  Catgut  ligatures  may  soften  or  absorb.  If  the  vessel  the  ligature 
is  holding  is  near  a  main  trunk,  the  pressure  behind  the  thrombus  may 
be  so  great  as  to  force  it  out  of  the  stump,  and  so  cause  late  hemorrhage. 

(5)  The  untied  distal  end  of  an  artery  may  bleed  when  collateral 
circulation  has  been  established. 

64 


INTERNAL  CONCEALED  HEMORRHAGE  65 

(6)  A  ligature  may  slip  if  it  is  not  tied  tight  enough;  if  the  knot  is 
poorly  done;  if  the  distal  tissues  have  been  severed  too  closely  to  the 
ligature.  If  in  the  removal  of  a  pedunculated  tumor  of  any  sort  the 
ligature  is  applied  with  the  pedicle  on  the  stretch,  and  this  is  then  cut  off 
close  to  the  ligature,  the  traction  on  the  elastic  arteries  is  relaxed  and 
they  have  a  tendency  to  retract  behind  the  ligature,  whereupon  they 
may  give  rise  to  serious  bleeding.  Hemorrhage  may  occur  as  a  result 
of  the  gradual  shrinkage  of  the  tissues  which  a  ligature  surrounds  and 
the  consequent  loosening  of  the  ligature,  as  in  the  uterus  after  Cesarean 
section  or  a  fibroid  enucleation, 

(7)  If  the  vessels  are  thin-walled  and  delicate,  as  the  veins  of  the 
omentum,  or  if  the  tissues  are  soft  and  friable  from  inflammation,  as 
•about  a  pus-tube,  a  ligature  tied  tightly  may  cut  through  the  vessel. 
Also,  if  the  arteries  are  atheromatous,  as  in  the  amputation  of  an  arterio- 
sclerotic uterus,  ligature,  especially  of  silk,  may  cut  through  them. 

The  symptoms  of  internal  concealed  hemorrhage  vary  with  the 
amount  of  blood  lost  and  the  rapidity.  It  is  not  the  loss  of  blood  alone 
which  causes  trouble;  there  is  the  element  of  shock  in  the  dynamic 
insult  to  the  heart-muscle  of  pumping  against  much  decreased  peripheral 
resistance  that  has  to  be  considered.  It  is  said  that  a  loss  of  from  4  to  lo 
ounces  will  suffice  to  bring  about  the  typical  picture  of  hemorrhage. 

The  onset  may  be  fulminating  in  character.  If  a  ligature  slips  from 
a  large  artery,  the  patient  will  start  up  suddenly,  cry  out  from  pain  as  the 
iDlood  rushes  into  her  peritoneal  cavity;  the  pulse  rises  in  a  moment  to 
130,  temperature  drops  to  subnormal,  respiration  becomes  hurried  and 
gasping,  the  face  becomes  pinched  and  ashy  pale,  and  death  ensues  in- 
side of  half  an  hour. 

Usually  the  story  is  longer,  but  no  less  typical.  The  patient,  apparently 
doing  well,  at  ten  to  thirty  hours  after  operation  begins  to  show  a  slight 
increase  in  the  pulse-rate.  At  the  same  time,  she  becomes  nervously 
aware  that  all  is  not  well,  she  can  feel  her  heart  beat,  and  she  has  harder 
work  in  breathing.  She  calls  for  a  glass  of  water,  and  asks  to  be  fanned 
or  to  have  the  windows  opened.  Then  she  has  a  sensation  of  pain 
referred  to  the  abdomen  from  the  presence  of  blood.  The  symptoms 
increase  at  the  end  of  an  hour.  The  pulse  has  reached  100  and  the 
respiration  26.  A  yellowish  pallor  is  spreading  over  her  face  and  her 
lips  are  blanched;  the  pupils  are  somewhat  dilated;  the  hands  and  feet 
become  cold  and  clammy,  and  a  cold  sweat  appears  on  her  forehead. 
By  the  end  of  the  second  hour  the  pain  and  anxiety  increase,  she  becomes 
restless,  tosses  about  in  bed,  and  throws  her  arms  over  her  head  to  help 
her  now  labored  respiration.     Her  temperature  is  subnormal.     Her  pulse 


66  POSTOPERATIVE   HEMORRHAGE 

-by  this  time  has  reached  140  and  the  respirations  are  30.  She  begs 
constantly  for  water  and  tries  to  get  rehef  in  sitting  up,  but  this  makes 
her  head  swim  round  uncomfortably.  Soon,  exhausted  by  her  struggle, 
cold,  with  dilated  pupils,  an  uncountable,  thready  pulse  and  rapid,  em- 
barrassed respiration,  she  dies. 

Although  shock  is  an  important  element  in  the  cause  of  death  from 
hemorrhage,  the  two  conditions  of  shock  and  hemorrhage  are  distinct 
clinical  entities  and  should  rarely  be  confounded.  The  patient  suffering 
from  protracted  shock,  or  delayed  shock,  often  is  apparently  most  phleg- 
matic, lying  quiet  and  motionless  in  bed,  stupidly  comfortable,  taking  a 
patronizing  interest  in  what  is  being  done  for  him.  The  patient 
with  hemorrhage,  on  the  other  hand,  is  nervous  and  restless,  panting 
for  air. 

The  diagnosis  of  internal  concealed  hemorrhage  is  always  made 
certain  by  signs  of  free  blood  in  the  peritoneal  cavity.  If  it  remains 
fluid,  there  will  be  dulness  in  the  flanks,  shifting  as  the  patient  turns 
upon  one  side  and  the  other.  If  it  clots,  it  presents  the  sensation  of 
boggy  fullness  and  resistance  and  dulness  which  does  not  change.  If 
blood  accumulates  in  the  pouch  of  Douglas,  it  may  be  felt  through  the 
vagina.  If  the  hemorrhage  is  between  the  folds  of  the  broad  ligament — 
that  is  to  say,  extraperitoneal — a  definite  mass  may  be  made  out  per 
vaginam,  pushing  the  uterus  forward  and  to  the  other  side  of  the  pelvis. 
An  examination  of  the  wound  dressings  should  never  be  neglected.  If 
the  wound  is  sutured  tight,  there  may  be  no  blood  upon  the  dressings. 
If  the  wound  has  been  drained,  the  gauze  of  the  dressings  is  apt  to  be 
saturated,  and  a  slight  loosening  of  the  drain  is  apt  to  be  followed  by  a 
flow  of  blood. 

Operative  Treatment  of  Superficial  Hemorrhage. — Ether- 
ize, reopen  the  wound,  clear  out  the  clot,  and  snap  and  tie  the  bleeding 
vessel.  If  the  patient  is  in  extremis,  the  wound  should  be  opened  im- 
mediately without  anesthesia,  a  hemostat  or  clamp  applied  and  left 
in  situ,  and  steps  taken  to  restore  the  patient.  If  the  bleeding  has 
ceased  when  the  surgeon  arrives  on  the  scene,  and  a  large  subcutaneous 
clot  is  in  evidence,  the  wound  should  be  opened,  unless  the  patient's  con- 
dition contraindicates,  and  the  clot  evacuated,  because  there  is  danger  0^ 
renewed  bleeding  as  soon  as  the  patient  recuperates,  and  the  presence  of 
a  mass  of  blood-clot  will  materially  delay  repair  and  interfere  with  first 
intention  healing,  if  it  does  not,  serve  as  the  nidus  for  secondary  infection. 
If  the  bleeding  is  venous  and  occurs  in  a  limb,  care  should  be  taken  that 
it  is  not  maintained  by  congestion  dependent  upon  tight  bandage  or 
dressings  proximal  to  the  wound. 


TREATMENT  67 

Operative  Treatment  of  Internal  Hemorrhage. — If,  after 
due  consideration,  it  has  been  decided  that  operation  is  necessary,  or  if,  in 
cases  of  collapse,  the  patient  has  revived  sufficiently  to  make  etherization 
feasible,  the  abdominal  wound  is  reopened  and  a  search  instituted  for 
the  source  of  hemorrhage.  Some  surgeons  make  it  a  rule  not  to  open  up 
the  entire  wound  at  once,  but  remove  only  a  few  of  the  stitches  at  one 
end,  and  through  these  enter  the  peritoneal  cavity.  If  the  procedure  is 
followed  by  a  gush  of  blood,  then  the  entire  wound  is  immediately  thrown 
open.  If  no  blood  follows,  a  large,  soft-rubber  catheter  is  introduced 
and  a  glass  syringe  attached,  to  be  used  as  a  sucker.  If  there  is  any  free 
blood,  this  apparatus  is  sure  to  locate  it.  If  none  is  found,  it  is  decided 
that  there  is  an  error  in  diagnosis,  or  that  the  bleeding  has  arrested  itself, 
and  the  patient  is  sewed  up  again. 

Most  men,  however,  after  having  made  a  definite  diagnosis  of  hemor- 
rhage, open  the  wound  from  end  to  end,  and  if  this  does  not  give  enough 
room,  may  enlarge  the  old  incision.  The  free  blood  and  clots  are  now 
rapidly  scooped  out,  and,  if  the  bleeding  point  does  not  present  at  once, 
a  search  is  made  over  the  field  of  operation.  Sometimes  the  wound  of  an 
artery  may  be  accidental,  and  is  found  at  some  distance  from  the  opera- 
tive site.  The  bleeding  vessel  once  found  is  tied  off,  the  abdomen 
washed  free  of  clots  with  sterile  salt  solution,  some  of  which  may  be  left 
in  the  abdomen,  and  the  abdomen  sewed  up.  If  the  patient  is  in  a  critical 
condition  and  time  is  an  object,  a  long-handled  clamp  may  be  applied  to 
the  artery  and  its  handle  left  projecting  through  the  wound,  to  be  removed 
at  the  end  of  forty-eight  hours.  If  the  bleeding  is  of  such  nature  that  it 
cannot  be  controlled  by  ligature  or  suture,  the  region  can  be  packed  firmly 
with  gauze  strips,  the  ends  of  which  are  left  hanging  through  the  wound. 
Oozing  from  a  denuded  surface  will  sometimes  respond  to  hot  water. 

SECONDARY  HEMORRHAGE 

*  The  term  secondary  hemorrhage  is  applied  to  that  form  of  hemor- 
rhage which  makes  its  appearance  some  days  after  the  operation,  and  is 
dependent  upon  erosion  of  a  vessel  by  the  extension  of  a  septic  process. 
This  condition  is  less  frequently  met  than  in  the  old  days  when  sepsis 
was  the  rule,  and  when  a  rubber  tourniquet  was  hung  over  every  bed  and 
the  ninth  day  awaited  with  trepidation.  It  is  to  be  feared  now  in  wide- 
spread and  deep  sepsis  of  a  limb  treated  without  amputation. 

Treatment- — Secondary  hemorrhage,  when  it  occurs,  comes 
furiously  and  practically  without  forewarning.  In  the  older  hospitals 
there  are  still  traditions  of  patients  being  left  for  a  few  moments  to  be 
found  exsanguinated  in  a  pool  of  blood. 


68  POSTOPERATIVE    HEMORRHAGE 

A  man  of  twenty-six  suffered  a  homicidal  large-caliber  bullet  wound  of  the 
abdomen.  At  the  operation  it  was  found  that  the  bullet  had  entered  at  the 
left  of  the  navel  from  above,  had  made  seventeen  wounds  of  intestine,  and  had 
then  buried  itseK  in  the  region  of  the  right  psoas  muscle.  Blood  and  intestinal 
contents  were  free  in  the  abdominal  ca\it}' .  Several  wounds  of  intestine  were 
sewed  and  two  resections  were  made.  All  mesenteric  hemorrhage  was  stopped 
by  ligature.  The  cavity  was  washed  out,  drains  were  left  in,  and  the  patient 
was  put  to  bed.  Convalescence  was  uninterrupted.  Some  mild  suppuration 
persisted,  however,  from  the  region  of  the  pehis,  into  which  the  bullet  had 
apparently  disappeared.     A  wick  was  in  this  sinus. 

On  the  twenty-third  day,  at  6  A.  M.,  the  patient  called  the  nurse  and  asked 
to  be  fanned.  One  glance  showed  the  patient  to  be  deathly  pale;  the  bed- 
clothes were  pulled  down,  and  the  patient  was  discovered  to  be  lying  in  a  bed 
literally  full  of  blood.  He  died  in  twenty  minutes,  and  autopsy  revealed  a 
suppurative  process  which  had  eroded  the  right  common  iliac  vein. 

Any  treatment  to  be  efficacious  must  be  immediate,  and  here  the 
tourniquet  and  digital  pressure  proximal  to  the  wound  are  to  be  relied 
upon  until  the  vessel  can  be  found  and  clamped.  If  the  sloughy  nature 
of  the  wound  makes  this  difi&cult  or  impossible,  the  wound  maybe  packed, 
or  the  old-fashioned  methods  of  the  actual  cautery,  acupressure,  or  t}'ing 
the  vessel  through  the  skin  by  using  a  curved  needle  some  distance  above 
the  wound  must  be  practised. 

Sometimes  the  condition  of  recurrent  hemorrhage  is  complicated  by  the 
presence  of  one  or  another  constitutional  diathesis,  as  hemophilia, 
leukocythemia,  jaundice.  In  this  case  the  bleeding  does  not  come  from 
a  single  vessel  which  can  be  tied  off,  but  is  in  the  form  of  a  general  ooze, 
and  the  above  rules  do  not  apply.  This  form  of  bleeding  may  occur 
from  the  moment  of  the  operation,  or  may  not  come  on  for  some  days 
afterward;  it  may  continue  interruptedly,  or  it  may  stop  for  some  hours 
and  then  start  afresh.  The  flow  of  blood  is  not  copious,  but  the  amount 
lost  is  often  considerable,  and  the  patient  may  soon  be  reduced  to  a 
dangerous  condition.  Such  hemorrhage  is  not  readily  amenable  to 
treatment,  and,  on  the  whole,  when  it  occurs,  is  one  of  the  most  trying  of 
all  complications  which  the  surgeon  has  to  face. 

If  the  diagnosis  of  any  of  these  conditions  is  made  before  operation, 
and  the  operation  cannot  be  postponed,  the  patient  should  be  given 
the  benefit  of  the  administration  of  large  doses  of  calcium  lactate  for  a 
few  days  before  as  well  as  ^.fter  the  operation,  in  order  to  increase  the 
coagulability  of  the  blood. 

Calcium  lactate  occurs  in  white,  granular  masses,  powder,  or  in  crystals,  is  odorless, 
and  has  scarcely  any  taste.     It  is  soluble  in  water  (i:  15),  less  so  in  hot  water,  slightly 


HEMORRHAGIC    DIATHESES  69 

soluble  in  alcohol,  and  insoluble  in  ether.  The  solubility  of  different  specimens  of  calcium 
lactate  varies  considerably  and  is  affected  by  age.  Calcium  lactate  is  given  before  opera- 
tions in  doses  of  i.or  2  gm.  (15  or  30  gr.).  The  ordinary  dose  is  0.5  to  4  gm.  (10  to  60 
gr.).  It  is  much  less  irritant  than  calcium  chlorid,  and  may  be  injected  subcutaneously. 
The  large  doses  now  given  may  be  suspended  in  water,  or,  as  this  salt  is  permanent  in  the 
air,  dispensed  in  powders  or  in  cachets. 

Calcium  lactate  should  be  fresh,  that  is,  it  should  form  a  clear  or  nearly  clear  solution 
in  water.     If  there  is  a  white  precipitate,  it  should  not  be  used.    It  may  be  given  as  follows: 

I^.     Calci.  lact lo.o 

Tinct.  capsici 0.3 

Aquae  chloroformis    ad  150.0. — M. 

Tablespoonful  in  water  three  times  a  day,  one  hour  before  meals. 

The  lactate  should  be  given  on  an  empty  stomach,  otherwise  it  is  likely  to  be  precip- 
itated by  the  phosphates  of  the  food.  Saline  aperients  are  contra-indicated  for  the  same 
reason,  and  to  relieve  the  constipation  which  the  calcium  salts  usually  induce,  other  cathartics 
should  be  employed. 

The  use  of  animal  sera  before  as  well  as  after  operation  has  been 
followed  by  good  results.  For  the  technique  of  their  administration 
see  Hemophilia  (Chapter  XXVIII). 

Locally  the  wound,  if  it  can  be  reached,  may  be  packed  with  gauze 
soaked  in  adrenalin  and  this  packing  renewed  frequently.  Other 
styptics,  such  as  Monsell's  solution,  may  be  used  in  the  same  way.  A 
styptic  is  useful  only  when  applied  while  the  bleeding  is  temporarily 
arrested.  The  clot  formed  by  the  styptic  must  be  actually  in  the  mouth 
of  the  vessel  and  not  on  the  surface  of  the  wound.  Pressure  alone  is 
rarely  of  much  assistance,  but  long-continued  digital  pressure  on  the 
artery  or  arteries  supplying  the  part,  or  even  ligation  of  these  arteries, 
when  feasible,  has  been  practised  with  success.  The  patient  should  be 
kept  quiet  by  opiates,  he  should  be  given  gelatin  lemonade  and  ice  to 
drink,  and  stimulation  by  brandy  or  digitalis  administered  as  necessary. 
Vasodilators  and  salt  solution  should  not  be  given.  Hemophilia  has 
been  treated  by  transfusion.^ 

Constitutional  Treatment. — The  treatment  of  these  conditions 
after  the  hemorrhage  has  been  securely  stopped  is  mainly  that  of  shock, 
but  before  it  is  certain  that  there  is  no  chance  of  further  bleeding,  great 
care  must  be  taken  that  the  arterial  tension  is  not  increased  either  by 
the  use  of  vasoconstrictors  or  of-  much  fluid  by  mouth,  by  rectum,  sub- 
cutaneously, or  by  transfusion.  The  use  of  vasodilators  is  clearly  contra- 
indicated.  Sometimes  the  patient  is  too  low  to  allow  of  operation  for 
the  control  of  bleeding.     The  condition  of  collapse,  with  its  state  of 

*  F.  O.  Allen,  Ann.  Surg.,  1906,  xviii,  625. 


70  POSTOPERATIVE    HEMORRHAGE 

lowered  tension,  favors  clot  formation,  and  during  collapse  hemorrhage 
may  be  stayed;  thus  the  expectant  is  sometimes  the  best  treatment  in 
slow  forms  of  internal  hemorrhage  with  the  patient  in  collapse. 

When  this  course  is  decided  upon,  the  patient  should  be  given  {  gr, 
morphin,  to  be  followed  by  ^q  g^.  every  half-hour,  and  nothing  else. 
If  the  loss  of  blood  is  overwhelming,  and  the  surgeon  has  no  question 
but  that  it  comes  from  a  large  radical  and  interference  will  be  necessary, 
a  patient  in  collapse  may  be  stimulated  temporarily  by  the  use  of  adre- 
nalin subcutaneously,  by  brandy,  strychnin,  strophanthin,  digitalis,  or 
camphor,  to  a  state  where  she  can  stand  ether  and  a  hurried  operation. 
It  is  to  be  remembered  that  in  coUapse  ether  inhaled  acts  as  a  temporary 
stimulant  within  certain  limitations,  and  also  that  in  collapse  but  little 
vapor  in  proportion  to  air  is  necessary  to  keep  the  patient  anesthetized. 
Ether  should  not  be  started,  however,  until  all  is  ready  for  the  opera- 
tion. Chloroform  should  not  be  used.  The  surgeon  should  plan  out 
his  course  of  action  before  he  starts.  He  should  work  rapidly  and,  if 
time  is  precious,  he  should  not  hesitate  to  leave  in  gauze  packing  or  a 
clamp.  After  the  operation  is  finished,  treatment  for  shock  should  be 
instituted  (Chapter  VH,  page  84). 

The  general  treatment  of  hemorrhage  may  be  summarized  as  follows : 
(i)  Lift  the  foot  of  the  bed  by  means  of  bed-blocks  or  a  chair.     This 
determines  the  flow  of  blood  to  the  medulla,  where  resides  the  vaso- 
motor center. 

(2)  Open  the  windows  and  allow  a  free  current  of  air  to  aid  in  the 
ready  oxygenation  of  the  blood. 

(3)  Apply  heaters  to  the  extremities  and  blankets  to  the  body  to  aid 
in  the  maintenance  of  body  heat. 

(4)  Apply  ice  locally — the  coldness  decreases  pain  and  constricts 
the  capillaries. 

(5)  Give  morphin  if  necessary  to  keep  the  patient  quiet  in  bed. 

(6)  Give  normal  salt  solution  intravenously  or  subcutaneously,  or 
normal  salt  solution  with  adrenalin,  or  employ  transfusion  of  blood 
from  another  individual  after  the  Heeding  has  ceased. 

(7)  Stimulate  by  means  of  enemas,  which  may  be  composed  of  black 
co'ffee  and  contain  ammonium  carbonate,  brandy,  or  strophanthin. 

(8)  Stimulate  by  means  of  subcutaneous  injections  of  strychnin, 
ether,  adrenalin,  strophanthin. 

TRANSFUSION 
The  transfusion  of  blood  has  recently  come  into  prominence  in  the 
treatment  of  hemorrhage. 


TRANSFUSION  71 

Transfusion  is  of  interesting  and  ancient  origin.''  It  was  known  to 
the  Egyptians  of  old  and  is  referred  to  in  the  works  of  the  Romans. 
The  earhest  known  authentic  case  is  that  of  Pope  Innocent  VIII,  who 
was  operated  upon  in  1492  by  his  Jewish  physician,  whose  name  has 
not  come  down.  The  blood  of  three  boys  was  passed  into  the  veins 
of  the  prelate,  but  without  marked  benefit.  The  discovery  of  the  cir- 
culation by  Harvey  gave  a  new  impetus  to  the  discussion  of  the  subject, 
and  research  was  instituted  upon  animals.  Lower,  in  1666,  wrote  the 
first  detailed  account  we  have  of  the  method  of  performing  transfusion, 
and  in  the  same  year  Jean  Denys,  in  France,  carried  on  similar  experi- 
ments. He  also  performed  the  operation  three  times  successfully  upon 
human  beings.  Following  his  report,  transfusion  was  carried  on  exten- 
sively, sometimes  from  animal  to  man,  and  sometimes  from  man  to 
man,  either  by  direct  communication  of  vessel  to  vessel  or  through  the 
mediation  of  a  quill  or  cannula  of  silver  or  of  bone,  or  indirectly  by  a 
syringe  or  pump.  Other  successes  were  reported,  but  the  method 
aroused  fierce  opposition,  and,  as  a  result,  in  France  the  procedure  was 
forbidden  (1668)  except  by  express  permit  of  the  Faculte  of  Paris. 

For  a  while  the  procedure  fell  into  disuse,  to  be  revived  from  time 
to  time  only  in  discussion,  until  about  the  year  1800,  when  it  was  again 
revived  and  given  an  important  position  in  experimental  physiology. 
Blundell,^  in  England,  did  important  research  upon  the  subject.  About 
this  time  also  it  was  first  noted  that  the  blood  of  an  imlike  species  would 
be  liable  to  cause  distressing  and  even  fatal  symptoms  in  the  person  in 
whom  it  was  injected.  About  1835  Bischoff  experimented  with  de- 
fibrinated  blood,  and  the  use  of  this  became  an  established  procedure 
up  to  about  the  middle  of  the  century.  In  1863  Blasius^  collected 
116  cases  of  transfusion  which  had  been  performed  during  the  preced- 
ing forty  years,  and  found  that  there  had  been  56  successful  results. 
All  these  cases  were  cases  of  indirect  transfusion,  and  in  two  the  source 
of  the  serum  was  an  animal. 

From  this  time  on  a  great  deal  of  attention  was  paid  to  transfusion, 
and  claims  of  a  highly  exaggerated  nature  were  advanced  and  new  and 
complicated  methods  originated.  The  transfusion  from  animals  to 
man  was  reintroduced,  but  after  Landois'  discovery  that  the  serum 
of  one  animal  may  have  the  property  of  destroying  the  red  corpuscles 
of  another,  the  use  of  heterogeneous  blood  was  given  up.  It  was  found 
also  that  defibrination  of  the  blood  created  a  source  of  danger,  inas- 

^  See  Landois,  Transfusion  des  Blutes,  Leipzig,  1875;  Ore,  1876,  quoted  by  Crile, 
Hemorrhage  and  Transfusion,  1909,  151. 

2  Medico-Chirurgical  Transactions,  1818,  ix,  56.  ^  Deut.  Klinik. 


72 


POSTOPERATIVE   HEMORRHAGE 


much  as  it  contained  a  fibrin  ferment  whicli  miglit  cause  intravascular 
coagulation.  These  limitations,  together  with  the  general  introduction  of 
intravenous  injection  of  normal  saline  solution,  about  1875,  brought 
about  a  gradual  disuse  of  transfusion,  which  lasted  until  some  time 
in  the  8o's,  when  it  was  taken  up  -with  renewed  enthusiasm. 

There  were  three  methods  of  transfusion  ordinarily  employed — 
the  intravascular,  the  intraperitoneal,  and  the  subcutaneous.  The 
work  of  Carrel  and  Guthrie  was  the  foundation  for  a  great  advance- 
ment in  the  use  of   the  intravascular  method.     As  a  result  of   their 


Fig.  32. — Transfusion  Instruments. 
A,  A,  Crile  carmulae,  four  \news;  B,  B,  Crile  clamps;  C,  C,  mosquito  forceps;  D,  fine  scissors;  E,  jeweler's  for- 
ceps; F,  Elsberg  camiula;  G,  Elsberg  hooks. 


experiments  a  practical  method  of  end-to-end  suture  of  \'essels  was 
perfected.  Crile^  simplified  this  technique  by  the  use  of  a  cannula 
adapted  from  that  which  had  already  been  introduced  by  Queirolo  and 
Payr.  Modifications  of  the  Crile  cannula  have  recently  been  introduced 
by  Elsberg  and  Bernheim. 

For  a  complete  exposition  of  the  subject  of  transfusion,  both  ex- 
perimental and  clinical,  the  reader  is  referred  to  Crile's  admirable  book. 
From  it  I  shall  quote  freely,  with  Dr.  Crile's  kind  permission. 

^  Hemorrhage  and  Transfusion,  New  York,  1909. 


TRANSFUSION 


73 


Technique.^ — "The  following  instruments  (Fig.  32)  and  materials 
have  been  found  to  be  most  helpful:  (i)  Scalpel;  (2)  blunt  dissector; 
(3)  small,  sharp-pointed  straight  scissors  for  dividing  the  vessels,  snip- 
ping off  fragments  of  the  adventitia,  and  so  forth;  (4)  ordinary  dis- 
secting forceps;  (5)  minute  tissue-forceps,  with  exact  approximation 
at  the  points  (those  used  by  the  watchmakers  have  been  found  to  be 
useful);  (6)  half  a  dozen  mosquito  hemostats,  to  use  in  securing  the 
minute  branches  of  the  radial  artery  and  the  small  venous  branches; 
(7)  a  pair  of  small  "Crile"  artery  clamps;  (8)  a  set  of  "Crile"  can- 
nulas; (9)  sterilized  vaselin;  (10)  the  ordinary  means  of  closing  a  wound, 
and  dressings. 


Fig.  33. — Transfusion.  (After  Crile.) 
Transfusion  by  Crile  cannula:  a.  Threading  the  vein;    b,  making  the  cuff;  c,  pulling  artery  over  cuffed  vein; 

d,  artery  tied  in  place. 

''The- vessels  to  be  anastomosed  are  exposed  (the  details  will  be 
described  later),  and,  after  selection  of  a  cannula  of  size  suitable  to 
the  size  of  the  vessels,  the  end  of  the  vein  is  either  pushed  through  the 
needle  end  of  the  cannula,  with  the  help  of  fine-pointed  forceps,  or 
pulled  through  by  means  of  a  single  fine  suture  inserted  in  its  edge, 
the  needle  being  left  on  the  suture  and  passed  through  the  cannula 
ahead  of  the  vgin.  The  handle  of  the  cannula  is  then  tightly  seized 
by  a  pair  of  hemostats  (the  fingers  are  too  clumsy)  (Fig.  33),  three  mos- 

^  Crile,  Hemorrhage  and  Transfusion,  284,  et  seq.      (Copyright,  1909,  by  D.  Appleton 

and  Company.) 


74  POSTOPERATIVE   HEMORRHAGE 

quito  hemostats  or  small  fine-pointed  forceps,  such  as  oculists  use,  are 
snapped  at  equidistant  points  on  the  end  of  the  vein,  taking  care  not 
to  have  the  tips  extend  up  into  the  lumen  more  than  is  necessary  to 
get  a  firm  hold.  The  end  of  the  vein  is  then  cuffed  back  over  the  can- 
nula by  gentle,  simultaneous  traction  on  the  three  hemostats,  and  tied 
firmly  in  place  with  a  fine  linen  thread  in  the  groove  nearest  to  the 
handle.  The  cuff'ed  part  is  next  covered  with  sterile  vaselin,  being 
careful  not  to  get  any  into  the  open  end.  This  facilitates  slipping  the 
artery  over  the  cuff.  The  hemostats  are  removed  from  the  full  edge 
and  the  artery  may  then  be  put  in  place. 

"  Owing  to  the  elasticity  of  the  arterial  wall,  it  usually  shrinks  con- 
siderably when  the  pressure  from  within  is  removed,  as  it  is  at  the 
free  end.  To  obviate  this,  it  may  be  necessary  to  dilate  the  end  very 
gently  by  inserting  the  closed  jaws  of  a  mosquito  hemostat  covered 
with  vaselin  and  opening  them  for  a  short  distance.  The  three  hemo- 
stats are  then  applied  to  the  edges,  just  as  with  the  vein,  and  the  artery 
is  gently  drawn  over  the  cuffed  vein  on  the  cannula  and  tied  in  place 
with  another  fine  linen  suture  applied  in  the  remaining  groove.  The 
mosquito  hemostats  are  removed,  and,  finally,  the  large  hemostat 
which  has  been  snapped  on  the  handle  of  the  cannula  during  all  this 
time  is  removed.  The  process  is  then  completed.  After  the  trans- 
fusion the  cannula  is  removed,  both  artery  and  vein  are  ligated,  and 
the  wounds  are  sutured. 

"In  making  a  cannula  anastomosis  experience  will  show  what  size 
cannula  is  suitable  for  the  given  vessels.  As  large  a  size  should  be 
used  as  possible,  without  injuring  the  intima  of  the  artery  by  stretching 
it  too  large.  Usually  there  will  be  no  difficulty  in  obtaining  a  large 
vein,  but  the  artery  may  be  very  small.  If  too  small  a  cannula  is  used, 
the  amount  of  the  flow  will  be  diminished.  Moreover,  too  large  a  vein 
will  take  up  too  much  room  in  the  cannula  and  the  amount  of  flow 
will  be  diminished. 

"  In  using  the  cannula  two  facts  should  be  particularly  remembered. 
The  first  is  that  the  long  axis  of  the  tube  should  coincide  with  the  long 
axis  of  the  lumen  of  the  vein  and  artery.  A  little  experimenting  will 
show  how  easily  the  cannula  may  be  made  to  slant  so  that  the  opening 
in  it  will  come  almost  in  contact  with  the  artery  wall  and  shut  off  the 
flow  in  great  part  or  completely.  Actual  experience  has  shown  the 
necessity  of  placing  the  cannula  accurately. 

"The  second  and  less  obvious  fact  is  that,  unless  the  right  amount 
of  tension  is  maintained  on  the  vessel  which  passes  through  the  can- 
nula when  the  blood  is  flowing  across,  particularly  with  a  small  cannula, 


TRANSFUSION 


75 


the  flow  will  be  diminished  or  shut  off  altogether  by  the  elasticity  of 
the  vessel  wall  on  tension  in  cannula,  pushing  the  outside  part  of  the 
vessel  in  and  blocking  the  way. 

"The  exposed  vessels  should  be  kept  moist  and  warm  with  normal 
saline  solution.  Not  only  is  drying  harmful,  but  the  flow  is  increased 
through  gradual  relaxation  of  the  arterial  wall. 

"  Experience  has  shown  that  if  anything  goes  wrong  in  carrying  out 
this  technique,  it  is  best  to  start  again  from  the  beginning,  and  not  to 
try  to  get  around  any  of  the  details  by  substitution." 

Other  forms  of  anastomosis,  direct  and  by  means  of  other  forms 
of  cannulae,  have  been  devised,  a  most  ingenious  technique  being  that  of 
Elsberg.^  He  employs  a  cannula  "built  on  the  principle  of  a  monkey- 
wrench,  which  can  be  enlarged  or  narrowed  to  any  size  desired  by 
means  of  a  screw  at  its  end  (Fig.  32).  The  smallest  lumen  obtainable 
is  about  equal  to  that  of  the  smallest  Crile  cannula,  and  the  largest 
greater  than  the  lumen  of  any  radial  artery.  The  instrument  is  cone- 
shaped  at  its  tip,  a  short  distance  from  which  is  a  ridge  with  four  small 
pin-points  which  are  directed  backward.  The  lumen  of  the  cannula 
at  its  base  is  larger  than  at  the  tip.  The  construction  of  the  cannula 
can  be  easily  understood  from  the  following  description  of  the  method 
of  using  it. 

"  The  radial  artery  of  the  donor  is  exposed  and  isolated  in  the  usual 
manner.  The  cannula,  screwed  wide  open,  is  then  slipped  under  and 
around  the  vessel.  It  is  then  screwed  shut  until  the  two  halves  of  the 
instrument  slightly  compress  the  vessel.  The  artery  is  then  tied  off 
about  one  centimeter  from  the  tip  of  the  cannula.  Before  the  vessel 
is  divided,  three  small-eye  tenacula  are  passed  through  the  wall  of  the 
artery  at  three  points  of  its  circumference,  a  few  millimeters  from  the 
ligature.  Small  mosquito  forceps  may  also  be  used.  These  are  given 
to  an  assistant,  who  makes  traction  on  them  while  the  operator  cuts 
the  vessel  near  the  ligature.  The  moment  the  artery  is  cut  the  stump 
is  pulled  back  over  the  cannula  by  means  of  the  tenacula  or  forceps, 
and  is  held  in  place  without  ligation  by  the  small  pin-points.  There 
is  no  bleeding  from  the  artery,  even  though  no  hemostatic  clamp  has 
been  applied,  because  the  cannula  itself  acts  as  a  hemostatic  clamp. 
The  vein  of  the  recipient  is  then  exposed  (but  not  freed) ;  two  ligatures 
are  passed  around  it;  one  is  tied  peripherally  in  the  usual  manner.  A 
small  transversa  slit  is  made  in  the  vein,  the  cannula  with  the  cuffed 
artery  inserted  into  the  vein,  a  ligature  tied  around  the  vein  and  can- 
nula screwed  open,  and  the  blood  allowed  to  flow.     The  rapidity  of 

^  Jour.  Am.  Med.  Assoc,  1909,  Hi,  887. 


76 


POSTOPERATIVE    HEMORRHAGE 


the  flow  can  be  varied  as  desired  by  the  size  to  which  the  instrument 
is  screwed  or  unscrewed  and  the  lumen  of  the  artery  is  never  diminished. 
"  It  will  be  noticed  that  the  artery  is  cuffed  instead  of  the  vein;  this 
method  I  believe  to  be  more  correct.  The  vein  is  the  larger  vessel, 
and  can,  therefore,  be  more  easily  telescoped  over  the  artery.  The 
vein  is  only  exposed,  not  freed,  and  the  artery  is  intubated  into  it. 

"  With  this  cannula  I  have  been  able  to  make  the  anastomosis  in  less 
than  four  minutes  after  the  artery  had  been  isolated,  and  have  found 
the  entire  procedure  a  simple  one.  The  advantages  of  the  instrument 
are  the  following: 

"  (i)  One  cannula  will  fit  any  vessel. 

"  (2)  The  cannula  is  applied  around  the  vessel  instead  of  the  vessel 
being  drawn  through  the  cannula. 

"  (3)  No  ligature  of  the  cuffed  vessel  is  required. 
"  (4)  The  cannula  itself  acts  as  a  hemostatic  clamp. 
"  (5)  The  cuffing  of  the  artery  is  easily  accomplished  without  strip- 
ping back  the  adventitia,  and,  therefore,  the  traumatism  to  the  artery 

wall  reduced  to  a  minimum. 

"  (6)  The  vein  need  only  be  exposed, 
not  dissected  out  and  cut. 

"  (7)  As  the  cannula  is  unscrewed  the 
blood  will  flow,  the  flow  can  be  regulated  at 
will,  and  lumen  of  the  artery  is  not  dimin- 
ished." 

.    I  will  quote  in  full  Bernheim's  description 
of  his  ingenious  improvement:^ 

"The  technique  of    the  transfusion  is  in 
most   respects  similar  to    that  used  for  the 
Crile  cannula.     The  vein  of  the  donee  is  care- 
fully isolated  and,  after  being  tied  off  distally 
and  secured  proximally  by  a  bull-dog  clamp, 
is    divided,    leaving    about    3    cm.   free    for 
manipulation.      The    lumen  of  the  vessel  is 
thoroughly  washed  out  with  warm  saline,  follo\\-ed  by  liquid  vaselin, 
after  which  all  superfluous  ad^•entitia  is  removed.     The  artery  of  the 
donor  is  prepared  in  a  similar  manner. 

"  The  vein  is  then,  by  means  of  a  needle  and  thread,  passed  through 
the  cannula  CFig.  34),  hook  end  first,  grasped  by  mosquito  clamps  at 
three  equidistant  points  along  its  lumen,  everted  over  the  cannula,  and 
impaled  on  the  three  hooks.     Next  the  artery  is  seized  in  a  similar 

^  A  Modification  of  the  Crile  Transfusion  Cannula,  Ann.  Surg.,  Oct.,  1909,  1,  786. 


Fig.    34. — Bernheim's    Modifica- 
tion OF  Crile's  Cannula. 


TRANSFUSION 


77 


manner  by  three  mosquito  clamps,  and,  after  being  gently  dilated,  ac- 
cording to  the  suggestion  of  Crile,  by  the  end  of  a  clamp  previously 
dipped  in  sterilized  oil,  is  gently  pulled  over  the  cannula  with  its  everted 
vein  and  also  impaled  on  the  three  hooks.  A  tie  is  now  placed  round  the 
cannula  for  the  sake  of  greater  security,  and  the  blood  allowed  to  flow, 
the  clamp  on  the  vein  being  removed  before  that  on  the  artery. 

"  The  advantage  of  this  over  the  ordinary  Crile  cannula  is  that  it  is 
absolutely  unnecessary  to  hold  either  vessel  while  the  tie  is  being  placed 
round  the  cannula.  This  difficulty,  slight  as  it  may  seem,  is  often  a 
most  serious  drawback  to  the  successful  performance  of  a  transfusion.^ 
As  a  matter  of  fact,  if  the  artery  has  not  been  too  much  dilated  before 
being  impaled  on  the  hooks  of  our  cannula,  no  tie  at  all  will  be  neces- 
sary, as  there  will  be  enough  pull  on  the  artery  and  vein  to  prevent 
leakage.  As  a  routine,  however,  we  think  it  best  to  put  one  tie  round 
the  cannula  and  vessels." 

Of  these  three  devices  for  transfusion,  the  cannula  of  Elsberg  is, 
in  my  opinion,  in  all  ways  the  most  satisfactory. 

General  Management  of  a  Transfusion. ^ — ''The  Donor. — 
First  of  all,  a  suitable  donor  must  be  obtained.  Both  men  and  women  are 
suitable.  In  cases  in  which  no  immediate  hurry  exists,  the  best  subject 
is  selected  from  among  the  relatives  and  friends  who  are  willing  to 
serve.  After  the  donor  has  been  selected,  he  is  subjected  to  a  full  cross- 
questioning  as  to  his  family  and  personal  history  and  a  thorough  phy- 
sical examination.  This  is  for  his  own  benefit  as  well  as  for  the  benefit 
of  the  patient.  The  regeneration  of  the  blood  lost  by  the  donor  is 
uninterrupted  and  rapid.  From  the  donor's  standpoint  the  duration 
of  flow  is  an  important  consideration.  The  best  way  of  determining 
when  to  stop  the  flow  is  by  watching  his  symptoms.  At  first  he  will 
show  loss  of  color  in  his  mucous  membranes,  pallor  of  the  skin,  slight 
uneasiness,  slight  quickening  of  the  pulse  and  respiration,  lowering 
of  the  blood  tension,  and  beginning  of  shrinkage  in  the  skin  of  the  face. 

^' The 'Recipient. — As  far  as  the  recipient  is  concerned,  transfusion 
is  a  problem  in  mechanics  as  well  as  in  therapeutics.  There  are  few, 
if  any,  operations  in  which  more  factors  must  be  considered  and  in 
which  more  care  must  be  exercised. 

"From  the  mechanical  standpoint,  the  chief  danger  to  he  feared 
is  acute  cardiac  dilatation  and  subsequent  cardiac  failure,  caused  by 
transfusion  in  excessive  amount  or  at  excessive  rate  of  flow.  Fortu- 
nately, a  certain  amount  of  dilatation  may  occur  and  pass  rapidly 
away  without  causing  either  immediate  or  subsequent  harm.     It  may 

^  T.  N.  Hepburn,  Ann.  Surg.,  1909,  xlix,  115.  ^  Crile,  loc.  cil. 


78 


POSTOPERATIVE   HEMORRHAGE 


be  necessary  to  shut  off  the  flow  altogether,  with  gentle  pressure  of 
the  fingers,  for  short  intervals,  giving  the  heart  a  chance  gradually  to 
assume  its  added  burden  by  allowing  only  small  amounts  of  blood  to 
cross  at  a  time. 

"The  principal  symptoms  of  acute  cardiac  dilatation  are  dyspnea, 
distress,  or  pain  in  the  upper  cardiac  region,  cough,  and  cyanosis;  the 
pulse  increases  in  rate  and  may  be  very  irregular  in  action,  tension, 
and  volume.  When  acute  dilatation  has  once  occurred  it  must  be 
promptly  recognized,  the  transfusion  must  be  stopped,  the  operating 
table  tilted  so  as  to  raise  the  patient  to  the  head-up  position,  and  rhyth- 
mic  pressure   made    on   the  chest  over  the  heart.     If  recovery  is  not 


Fig.  35. — Transfusion.     (After  Crile.) 
Diagram  to  show  arrangement  of  operating  room:     i   2,  Operating  tables  for  recipient  and  donor,  respec« 
lively;  3,  table  for  arms  of  recipient  and  donor;  4,  5,  stools  for  surgeon  and  first  assistant,  respectively;  6,  instru- 
ment table;  7,  table  for  dressings,  sutures,  etc. 

complete  in  a  short  time,  transfusion  should  be  given  up  and  the  patient 
put  to  bed  in  a  head-up  position,  given  carefully  graded  doses  of  nitro- 
glycerin to  insure  peripheral  dilatation  of  the  vessels  and  digitalin 
hypodermically  in  very  small  doses  to  stimulate  the  heart-muscle  directly. 

"The  treatment  is  a  question  of  therapeutics  when  reduced  to  its 
final  analysis.  The  surgeon  takes  the  place  of  the  internist  when  he 
gives  a  'dose'  of  blood. 

"The  question  of  dosage  may  be  very  important,  especially  when 
there  is  hemolysis  of  the  recipient's  red  corpuscles  by  the  donor's  serum; 
therefore,  in  all  but  emergency  cases,  preliminary  hemolysis  tests  should 
be  made  in  order  to  handle  a  given  transfusion  more  intelligently  and 
protect  the  recipient  more  fully."  ^ 

^  For  the  technique  of  these  tests,  see  Crile,  loc.  cit.,  313. 


TRANSFUSION  79 

"  The  Operation. — It  is  a  great  advantage  to  have  a  thoroughly 
trained  corps  of  assistants.  Two  operating  tables  are  necessary  (a  single 
large  bed  in  a  private  house  will  do).  Two  small  square  tables  of  the 
same  height  as  the  operating  tables  are  needed — one  for  the  instruments 
and  the  other  to  support  the  arms  of  the  patients.  Two  low  stools, 
one  for  the  surgeon  and  one  for  the  first  assistant,  complete  the  list. 

"From  twenty  to  thirty  minutes  before  being  brought  to  the  operat- 
ing room  the  donor  and  recipient  each  receive  morphin  sulphate,  gr.  \, 
hypodermically,  unless  there  is  some  special  reason  for  its  being  contra- 
indicated. 

"When  each  is  in  place  on  his  respective  table,  the  tables  are  so 
arranged  that  the  left  arm  of  each  will  rest  comfortably  on  the  small 
table,  placed  for  the  purpose  between  the  operating  tables  (Fig.  35). 
The  patients  are  told  that  there  will  be  no  pain  beyond  the  first  needle- 
prick.  The  nurse  who  is  detailed  to  care  directly  for  the  patients  re- 
lieves the  monotony  of  waiting  by  bathing  the  forehead,  giving  water 
to  drink  if  desired,  and,  in  short,  doing  anything  permissible  to  afford 
comfort. 

"The  next  step  is  the  dissection  of  the  blood-vessels.  Experience 
has  shown  that  it  is  best  to  use  a  radial  artery  of  the  donor  and  any 
superficial  arm  vein  of  the  recipient  near  the  elbow.  Usually  the  median 
basilic  vein  is  the  best  one,  on  account  of  its  size  and  easily  accessible 
position. 

"Local  anesthesia  is  obtained  by  injecting  cocain  in  -j^  of  i  per 
cent,  solution  with  a  few  drops  of  i  :  1000  adrenalin  chlorid  solution. 
Several  hypodermic  syringes  should  be  ready,  so  that  there  need  be  no 
delay  on  account  of  having  to  stop  to  refill  a  single  one.  The  injec- 
tions are  first  made  in  the  skin  and  then  more  deeply  round  the  vessels. 

"In  making  the  dissection  it  is  necessary  to  have  good  light.  Mos- 
quito hemostats  are  used  to  catch  every  vessel  that  shows  even  a  drop 
of  blood.  The  vessel  should  be  kept  absolutely  clean.  The  donor's 
radial  artery  is  isolated  for  a  distance  of  about  3  cm.  at  the  point  of 
election  in  the  wrist.  Here  there  are  a  number  of  small  side  branches 
which  must  be  carefully  isolated  and  tied  with  a  No.  i  Chinese  twist 
silk  before  being  cut.  The  artery  is  then  tied  at  its  distal  end,  and  a 
Crile  clamp  is  gently  screwed  in  place  over  the  approximate  part,  as. 
near  to  the  place  where  it  comes  but  of  the  undissected  tissues  as  con- 
venient. The  clamp  should  be  screwed  up  with  great  care.  Just 
enough  pressure  should  be  used  to  control  the  flow  of  blood  without 
causing  injury  to  the  vessel  wall.  The  artery  is  severed  with  sharp 
scissors  a  short  distance  from  where  it  is  tied  off,  the  end  cut  squarely 


8o  POSTOPERATIVE   HEMORRHAGE 

across,  the  adventitia  pulled  down  and  cut  off,  and  is  then  ready  for 
the  completion  of  the  anastomosis.  The  result  should  be  that  the 
operator  has  about  2^  cm.  of  the  exposed  radial  artery  free  from  branches, 
the  ciit  end  open,  and  the  blood  prevented  from  coming  out  of  it  by  the 
clamp. 

"The  next  step  is  the  dissection  of  the  vein.  It  is  exposed  for  the 
same  distance  as  the  artery,  the  branches  are  tied  off  in  the  same  way, 
and  the  ligature  is  also  applied  at  the  distal  end.  The  second  Crile 
clamp  is  applied  just  as  before,  the  vein  cut  near  the  ligature,  and  it  in 
turn  is  ready  for  the  completion  of  the  anastomosis." 

Dr.  Crile  concludes  his  remarkably  explicit  and  complete  work  on 
the  subject  thus: 

"Transfusion,  when  properly  safeguarded,  may  be  safely  done. 

"In  pernicious  anemia,  toxemia,  certain  drug  poisonings,  leukemia, 
acute  hyperthyroidism,  carcinoma,  and  uremia  it  has  been  of  no  value. 

"In  tuberculosis  and  chronic  infections  it  has  certain  value;  in 
pathologic  hemorrhage  it  is  of  marked  value. 

"If  done  in  time  transfusion  is  specific  in  acute  hemorrhage.  In 
suitable  cases  it  seems  to  be  almost  specific  in  the  prevention  and  treat- 
ment of  shock. 

"Judiciously  employed,  transfusion  will  surely  prove  a  valuable, 
often  life-saving,  resource;  injudiciously  employed,  it  will  surely  become 
discredited." 


March  23,  1908,  Mrs.  B.,  seen  in  consultation  with  Dr.  C.  N.  Cutler, 
Chelsea,  Massachusetts. 

P.  H.  On  this  patient  I  had  operated  for  left  extra-uterine  pregnancy 
September  5,  1907. 

P.  I.  Two  days  ago  collapse,  pallor,  gasping  respiration,  pulse  180, 
abdominal  pain  beginning  low;  great  tenderness  but  no  spasm.  Diagnosis, 
ruptured  extra-uterine  pregnancy.  Patient  too  sick  for  operation;  yester- 
day patient  better,  pulse  down  to  140,  but  this  morning  at  4  o'clock 
another  collapse  with  pain.  Pulse  160  and  temperature  101°  F.;  gasping 
respiration;  distention,  abdominal  spasm. 

Operation. — Assisted  by  Drs.  Cutler,  Ehrenfried,  and  Osgood,  and  four 
nurses.  At  the  moment  of  operation,  adrenalin  salt  solution  (i  :  50,000) 
started  under  the  breasts,  one  quart  jn  all  taken.  Median  celiotomy.  On 
right  parovarium  ruptured  pregnancy  mass  found.  Fetus  size  of  a  thumb- 
nail found  at  once  floating  free  on  intestines.  Two  quarts  free  clot  and 
fresh  blood.  This  was  rapidly  sponged  out,  the  mass  and  right  tube  tied 
off,  salt  solution  left  in  abdomen,  and  wound  closed  with  one  layer  of 
through-and-through    sutures.       Duration    of    operation,    sixteen    minutes. 


TRANSFUSION  8l 

Patient  cold,  no  pulse  at  wrist,  respiration  40.  Patient  placed  on  bed 
with  heaters;  foot  of  bed  raised.  Strychnin  sulphate,  gr.  -g-'^,  subcutane- 
ously;  transfusion  from  left  radial  artery  of  patient's  brother  into  left 
median  basilic  vein  of  patient  continued  twenty -five  minutes.  The  vessels 
were  large  and  the  volume  of  the  brother's  pulse  was  full.  At  the  end  of 
twenty-five  minutes  the  transfusion  was  stopped.  The  patient  had  a  fairly 
good  pulse  at  the  wrist,  rate  156,  the  skin  had  changed  from  cadaveric 
yellow  to  a  more  natural  color,  and  there  was  a  distinct  pink  in  the  lips: 
the  gasping  respiration  ceased  entirely  and  the  patient  slept  quietly. 
Uneventful  recovery. 

B.  B.,  aged  eight,  seen  in  consultation  with  Dr.  Provandie,  Melrose, 
Massachusetts.  The  patient  had  had  his  tonsils  removed  by  guillotine 
about  nine  hours  before,  had  apparently  been  bleeding  down  his  throat 
all  day,  and  at  6  p.  m.  collapsed,  with  pulse  160,  temperature  97.2°  F.,  res- 
piration 42,  slight  cyanosis. 

A  Crile  transfusion  was  done,  using  the  mother,  under  cocain,  as  the 
donor,  the  boy  being  etherized.  The  flow  was  carried  on  fifty-six  minutes, 
at  the  end  of  which  the  boy  was  nearly  normal  in  color,  pulse  better  vol- 
ume, but  still  140  in  rate.  It  seems  likely  that  he  had  too  large  a  dose 
of  blood,  though  no  increased  cardiac  area  could  be  made  out.  The  next 
day,  to  bear  this- out,  there  were  some  signs  of  congestion  of  the  lungs, 
but  recovery  was  uneventful. 
6 


CHAPTER  VII 

SHOCK:   CAUSES,  SYMPTOMS,  TREATMENT 

Shock  is  a  condition  of  reflex  depression  of  the  vital  functions  which, 
occurs  after  serious  injuries  and  operations,  but  may,  apparently, 
result  also  from  mental  excitement  induced  and  accompanied  by  com- 
paratively slight  bodily  injury.  Every  operation  of  any  severity  is 
accompanied  by  some  degree  of  shock.  It  may  vary  in  intensity,, 
from  a  transient  state  of  weakness,  which  reacts  readily  to  stimulation,, 
to  the  most  profound  condition  of  vital  depression  which  resists  all 
efforts  at  alleviation  and  is  the  cause  of  death.^ 

We  may  consider  as  the  cause  of  shock  any  sudden,  severe,  or  pro- 
longed irritation  of  the  peripheral  nerves,  especially  of  the  sympathetics, 
and  of  nerves  not  accustomed  to  carrying  impulses  of  tactile  sensation 
from  the  surface  of  the  body.  Thus,  shock  will  follow  severe  blows 
upon  the  head,  larynx,  abdomen  ("solar  plexus"),  testicle,  or  sper- 
matic cord,  abdominal  wounds  and  visceral  injury,  gunshot  wounds 
of  the  intestine,  and  perforation  of  the  bowel  in  typhoid  or  appendicitis. 
Hemorrhage  causes  collapse  and  not  shock.  Shock  most  frequently 
follows  operations  involving  the  abdominal  contents  and  visceral  peri- 
toneum, next  the  visceral  pleura,  third,  the  male  generative  organs. 
In  abdominal  operations  the  state  of  shock  seems  to  bear  some  propor- 
tion to  the  amount  of  manipulation  the  visceral  peritoneum  receives, 
or  the  amount  of  exposure  of  the  viscera.     In  abdominal  surgery  the 

^  Seelig  and  Lyon  (Jour.  Am.  Med.  Assoc,  1909,  lii,  45)  refer  to  Groeningen  (Ueber 
den  Shock,  Weisbaden,  1885)  for  history.  The  idea  that  shock  was  due  to  vasomotor 
exhaustion  was  first  enunciated  in  1864  by  W.  W.  Keen,  S.  Weir  Mitchell,  and  C.  W. 
Moorehouse.  (See  circular  No.  6,  Surgeon-General's  Ofl&ce,  1864.)  This  was  later  con- 
firmed by  Fisher  and  restated  by  Crile.  Leydon  (Samml.  klin.  Vortr.,  1870,  No.  2)  and 
Meltzer,  S.  J.  (The  Nature  of  Shock,  Archiv.  Int.  Med.,  1908,  i,  571)  held  that  shock 
was  due  to  a  reflex  inhibition  of  the  activity  of  the  centers  of  the  cord.  The  only  other 
theory  of  importance  is  that  recently  expounded  by  E.  Boise  (Am.  Jour,  of  Obstetrics, 
1907)  that  cardiac  exhaustion  is  the  main  underlying  factor. 

As  the  problem  stands  to-day,  there  are  several  contradictory  theories.  Crile  and  his 
followers  declare  that  vasomotor  exhaustion  is  the  primary  cause  of  shock  (Blood  Pressure 
in  Surgery,  Phila.,  1903;  An  Exp'erimental  Inquiry  into  Surgical  Shock,  Phila.,  1899). 
Boise  states  that  cardiac  exhaustion  is  the  prime  cause,  whereas  W.  H.  Howell  (Amer. 
Med.,  1904,  482)  believes  that  both  these  factors,  namely,  cardiac  and  vascular,  must  fje 
reckoned  with. 
82 


ETIOLOGY  83 

tendency  to  shock  is  least  after  operations  upon  the  pelvic  organs,  and 
greatest  in  operations  on  the  stomach  and  duodenum.  In  operations 
on  the  extremities  the  amount  of  shock  bears  a  proportion  to  the  sen- 
sory nerve  supply  of  the  tissues  destroyed  or  manipulated.  Pain  is 
an  important  factor  in  causing  or  prolonging  shock. 

Recently  the  etiology  of  shock  has  been  cleared  up  somewhat  by 
experimental  investigations  on  animals.^  Our  present  notions  may 
be  summarized  as  follows:  Overstimulation  of  the  sensory  nerves 
and  the  severe  and  unaccustomed  stimulation  of  nerves  not  ordinarily 
carrying  impulses  of  sensation  lead  to  a  rapid  exhaustion,  and  finally 
temporary  suspension  of  function  in  the  corresponding  centers.  Ac- 
companying, and  as  a  result  of  this,  there  comes  the  dilatation  of  the 
vessels  of  the  part  which  originally  suffered  mechanical  insult.  The 
heart,  its  innervation  already  somew^hat  disturbed  by  the  disturbance 
of  the  other  nerve-centers,  works  harder  and  faster  to  maintain  the 
blood-pressure,  which  has  been  lowered  by  this  vasodilatation.  Sooner 
or  later,  unless  the  vasomotor  center  recovers  its  tone,  or  relief  comes 
from  without,  the  heart-muscle  begins  to  tire  and  finally  to  give  way, 
and  the  picture  of  extreme  shock  develops.  The  blood-pressure  drops; 
the  blood,  withdrawing  from  active  circulation,  stagnates  in  the  readily 
distensible  veins  of  the  splanchnic  area,  where  it  interferes  with  the 
action  of  the  heart,  and  the  blood  fails  to  become  properly  oxygenated. 
As  a  result,  the  vasomotor  center  is  insufficiently  supplied  with  blood, 
which  is  of  an  improper  quality.  This  further  disturbance  reacts  upon 
the  heart,  which  wears  itself  out,  pumping  faster  and  faster  its  inade- 
quate supply  in  the  attempt  to  maintain  the  normal  blood-pressure,  until 
it  exhausts  itself  and  death  ensues.^ 

Clinically,  shock  may  be  immediate,  coming  on  during  or  imme- 
diately after  an  operation;  deferred,  six  to  twenty-four  hours'  after 
operation;   and  continued,  coming  on  soon  after  operation,  and  lasting 

1  p.  L.  Mummery  and  W.  L.  Symes  (Brit.  Med.  Jour.,  1908,  ii,  786,  Experimental 
Production  and  Control  of  the  Vascular  Anatomy  of  Surgical  Shock)  tell  us  that  in  fully 
anesthetized  animals  manipulations  of  abdominal  viscera  are  more  productive  of  shock 
than  are  gross  injuries.  Such  manipulations  produce  shock  rapidly  when  they  implicate 
the  parietal  peritoneum  and  the  mesenteries.  Shock  is  more  rapidly  produced  under 
chloroform  than  under  ether. 

2  Eisendrath  and  Strauss  (Some  Postoperative  Complications,  International  Clinics, 
1909,  iii,  114):  "Collapse  differs  from  shock  in  this  respect  only,  viz.,  in  collapse  there  is 
a  sudden  overpowering  impulse  which  inhibits  the  vasomotor  center  temporarily,  while 
in  shock  this  center  is  in  a  state  of  exhaustion  from  long-continued  peripheral  irritation. 
When  collapse  following  a  severe  hemorrhage  has  persisted  for  a  considerable  time,  it 
begins  to  change  into  a  condition  of  shock,  as  the  vasomotor  center  becomes  exhausted  in 
an  effort  to  maintain  the  blood-pressure  at  the  same  level." 


84  shock:  causes,  symptoms,  treatment 

twenty-four  to  forty-eight  hours  or  even  three  or  four  days.  The  tw^o 
latter  varieties  are  uncommon.  What  is  called  deferred  shock  may 
sometimes  be  the  collapse  of  secondary  hemorrhage.  Continued 
shock  is  like  ordinary  shock,  except  that  the  symptoms  are  slower  in 
developing  and  that  it  runs  a  longer  course.  It  is  apt  to  occur  after 
prolonged  operations,  in  cases  accompanied  by  severe  mental  shock  or 
pain,  and  in  anemic  women. 

Symptoms. — The  symptoms  are  analogous  in  all  forms  and  ex- 
tremely typical.  Rarely  the  onset  of  shock  will  be  so  sudden  and  its 
development  so  rapid  that  the  patient  will  die  on  the  table.  This 
fulminating  form  is  not  to  be  confounded  with  asphyxia  due  to  the 
anesthetic.  Usually  the  condition  develops  gradually  as  the  operation 
proceeds,  the  pulse-rate  increases,  and  soon  the  volume  and  tension 
decrease,  the  surface  temperature  drops,  the  respiration  becomes  faster^ 
and  less  deep,  and  the  face  and  lips  become  pallid,  and  the  pupils  dilate. 
The  immediate  indication  is  to  end  the  operation  and  treat  the  patient; 
patients  in  this  stage  may  be  expected  to  react.  As  the  condition  pro- 
ceeds the  pulse  becomes  irregular  and  thready,  the  skin  cold,  pallid, 
and  covered  with  a  cold  sweat,  the  lips  become  blue,  and  the  respira- 
tion shallow  and  irregular.  The  patient  is  put  to  bed  in  a  state  of 
dull  torpor,  which  gradually  develops  into  coma.  The  pupils  are 
dilated  and  the  eyes  half  closed  and  staring.  There  is  loss  or  impair- 
ment of  surface  sensibility  and  the  phlegm  which  collects  in  the  throat 
is  audibly  churned  with  the  respiration.  Occasionally  there  is  hic- 
cough, nausea,  and  even  vomiting;  there  is  loss  of  muscle  control; 
there  may  be  incontinence  of  feces,  lessened  secretion,  and  retention 
of  urine.  Rarely,  instead  of  the  commonly  expected  picture  of  men- 
tal inactivity  and  apathy  we  find  excitation  and  maniacal  delirium, 
which  exhausts  itself  rapidly  and  develops  into  coma. 

If  the  patient  responds  to  treatment,  there  will  be  a  gradual  develop- 
ment of  consciousness,  often  preceded  by  vomiting,  and  the  patient 
in  a  husky  voice  will  ask  for  water.  The  corneal  and  cutaneous  reflexes 
will  be  reestablished,  the  pulse  become  stronger  and  slower,  the  skin 
become  warmer  and  lose  its  clammy  appearance,  the  respirations 
become  slower  and  deeper,  and  the  kidneys  begin  to  secrete  urine. 
If  there  is  no  pain  the  patient  will  often  sink  into  normal  sleep,  to  awake 
in  a  few  hours  much  improved. 

Treatm.ent. — In   treatment    the    matter    of  prophylaxis    has   an 

^  J.  Henderson  (Apnea  and  Shock,  Amer.  Jour,  of  Physiology,  1909,  xxiv,  66)  says 
that  increased  rapidity  of  breathing  leads  to  an  unusual  loss  of  carbon  dioxid  and  shock 
is  the  result. 


PROPHYLAXIS  85 

important  place.  Before  operation  the  bowels  should  be  empty, 
although  overfree  saline  catharsis  causes  depletion  of  tissues  and  should 
be  avoided.  Starvation  should  not  be  practised;  the  patient  should 
be  well  fed,  and  may  even  have  a  cup  of  bouillon  or  coffee  and  a  cracker 
an  hour  before  ether  is  started  if  she  feels  the  need  of  it,  or  a  nutrient 
enema  may  be  given  one-half  hour  before  the  operation.  The  patient 
should  be  in  a  quiet  frame  of  mind,^  and  should  have  a  good  night's 
sleep,  otherwise,  if  she  is  restless  or  in  pain,  morphin,  gr.  |,  and  atropin, 
gr.  X2T'  should  be  administered  one-half  hour  before  operation.  This 
use  of  atropin  before  operation  in  cases  where  shock  is  feared  is  at  least 
theoretically  sound,  for,  besides  "guarding"  the  morphin,  it  depresses 
the  vagus,  and  by  central  action  in  small  doses  induces  constriction 
of  abdominal  arterioles,  although  with,  in  a  less  degree,  a  compensa- 
tory dilatation  of  the  peripheral  vessels.  There  is  some  clinical  and 
experimental  evidence  confirmatory  of  this  beneficial  action.  On  the 
whole,  it  is  wise  to  avoid  the  routine  preoperative  use  of  drugs  to  pre- 
vent shock;  drugs  should  be  withheld  until  a  definite  indication  for 
their  use  appears.  Ether  is  always  the  anesthetic  of  choice  if  shock  is 
feared. 

If  the  patient  is  brought  to  the  surgeon  in  a  state  of  severe  shock,  as, 
for  instance,  from  a  mutilating  trauma,  he  will  have  to  decide  whether  to 
superimpose  upon  the  existing  condition  the  shock  of  ether  and  opera- 
tion or  to  temporize  and  combat  shock  before  operation.  There  seems 
to  be  among  active  surgeons  a  growing  tendency  in  favor  of  the  latter 
course.  Many  a  forlorn  hope  has  been  rushed  to  the  table  to  expire 
during  the  operation  or  soon  after  its  close,  where  the  operative  risk 
might  have  been  lessened  in  cases  that  could  wait  if  a  few  hours  were 
given  first  to  the  treatment  of  shock. 

During  the  operation  much  may  be  done  to  forestall  shock ;  if  shock 
is  expected,  all  precautions  should  be  taken.  In  the  first  place,  the 
operation  should  be  rapid,  even  to  going  through  the  abdominal  wall 
with  one  stroke  of  the  knife  if  indicated.  All  preparations  should  be 
made  and  everything  well  planned  before  the  anesthetic  is  started.  It 
is  vastly  important  that  the  period  of  anesthesia  be  as  short  as  pos- 
sible. Everything  should  be  made  ready  for  the  treatment  of  post- 
operative shock  while  the  operation  is  going  on,  and,  if  the  occasion 
demands,  hypodermoclysis  of '  normal  salt  solution  may  be  carried 
out  beneficially  while  the  operation  is  under  way. 

^  Crile  (Surgical  Shock,  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  961)  discusses 
certain  phases  of  shock  in  their  relation  to  surgical  practice.  He  dwells  particularly 
on  the  psychic  element  in  prophylaxis  and  warns  against  ovcrancsthesia. 


86  shock:  causes,  symptoms,  treatment 

All  measures  should  be  taken  to  prevent  the  loss  of  body  heat.  The 
room  should  be  warm,  about  72°  F.,  and  an  operating  table  heated  by 
steam  or  electricity  may  advantageously  be  used.  The  body  and 
limbs  should  be  well  wrapped  in  blankets;  hot-water  bottles  should  be 
used  freely  if  necessary,  and  especial  care  should  be  taken  that  the 
patient  is  not  lying  exposed  upon  uncovered  cold  glass  plates  or  that 
the  blankets  or  towels  are  allowed  to  become  wet  without  being  changed. 
The  room  should  be  well  ventilated,  especially  in  operations  of  any 
length,  so  as  to  allow  the  patient  a  proper  supply  of  oxygen. 

Loss  of  blood  should  be  scrupulously  avoided,  especially  in  anemic, 
cachectic,  or  exsanguinated  persons.  All  unnecessary  exposure  or 
manipulation  of  intestines  should  be  guarded  against;  coils  of  intestine 
should  be  replaced  with  considerate  gentleness  as  soon  as  practicable, 
and,  if  exposed  necessarily,  should  be  kept  covered  with  sterile  towels 
or  large  pads,  hot  with  sterile  salt  solution  frequently  renewed.  The 
omentum  is  much  less  sensitive  to  handling  than  the  intestines.  In  a 
limb  the  cocainization  of  the  sensory  nerve-trunk  supplying  the  part — - 
"blocking"  the  afferent  track — before  any  gross  mutilation  or  rough 
handling  is  to  be  performed,  as  in  cleaning  up  and  repairing  an  ankle 
after  a  bad  crush,  will  forestall  or  lessen  shock.  If  shock  is  imminent, 
the  lowering  of  the  head  by  the  assumption  of  the  Trendelenburg  pos- 
ture will  relieve  cerebral  anemia. 

With  the  condition  of  shock  established,  certain  indications  for  treat- 
ment present  themselves.    These  we  shall  consider  in  the  following  order : 

(i)  Fall  in  blood-pressure  due  to  distention  of  the  vessels  of  the 
splanchnic  area. 

(2)  Rapid  heart  action  due  to  withdrawal  of  blood  from  the  active 
circulation,  causing  dynamic  exhaustion  of  the  heart  from  working 
against  too  low  resistance. 

(3)  Anemia  of  the  brain,  and  of  the  vasomotor  center  especially,  from 
lessened  amount  and  poor  aeration  of  blood-supply. 

(4)  Cardiac  exhaustion  from  progressive  weakening  of  the  heart- 
muscle. 

(5)  Pain  as  an  element  in  causing  or  prolonging  shock. 

(6)  General  measures  in  the  care  of  patients. 

Crile  has  recently  demonstrated  on  animals  that  the  main  factor  in 
shock  is  a  general  fall  in  the  blood- pressure  in  the  peripheral  arteries, 
with  a  coincident  rise  in  pressure  in  the  vessels  of  the  portal  system. 
Leaving  the  abdomen  full  of  sterile  salt  solution  after  a  celiotomy  will 


TREATMENT  87 

temporarily,  at  least,  create  a  positive  pressure  which  will  partially 
counteract  or  prevent  this  dilatation  of  the  splanchnic  vessels.  After 
the  operation,  the  application  of  a  binder  over  the  abdomen,  as  tight  as 
can  be  borne,  padded  in  the  middle  line  with  folded  towels,  is  also  use- 
ful in  overcoming  the  vascular  distention.  Hunter  Robb  has  lately 
suggested  the  use  of  weights  hung  across  the  abdomen  for  the  same 
purpose,  and  Momberg  proposes  a  rubber  tube  tightly  drawn  about  the 
body  just  below  the  costal  arch.^  It  is  here  also  that  the  usefulness  of 
the  vasoconstrictors  is  apparent,  and  of  these  we  shall  consider  adrenalin, 
caffein,  and  strychnin.  Digitalis  also  acts  secondarily  by  constricting 
the  splanchnics,  but  we  shall  consider  this  drug  later. 

Adrenalin  is  the  most  active  member  of  this  group,  and  perhaps  its 
best  indication  for  use  is  in  shock.  It  induces  a  prompt  and  marked 
rise  in  blood-pressure  by  acting  directly  on  the  muscle-tissue  of  the 
arteries  to  cause  contraction  of  the  peripheral  vessels.  Whether  or  not 
it  is  capable  of  influencing  directly  the  splanchnic  vessels  is  still  un- 
determined. The  ordinary  dose  is  5  to  15  minims  of  the  i  :  1000 
solution.  It  must  be  given  subcutaneously  or  intravenously,  as  its 
vasomotor  action  is  absent  when  given  by  mouth.  The  administra- 
tion of  drugs  by  mouth  should  be  avoided  in  shock,  as  patients  do  not 
react  normally  to  sensory  stimuli,  and  the  reflexes  connected  with  the 
act  of  swallowing  are  dulled,  so  that  the  irritating  fluid  may  readily  pass 
into  the  larynx. 

Adrenalin  may  conveniently  and  rationally  be  given  in  salt  solu- 
tion infusion,  15  minims  to  the  quart  (1:50,000  solution).  Its  ac- 
tion is  very  transitory,"  lasting  only  about  ten  minutes,  so  that  if  the 
desired  effect  is  not  obtained,  it  must  be  repeated.  Its  effect  in  increas- 
ing the  blood-pressure  may  be  so  marked  as  to  lead  to  acute  dilatation 
in  a  diseased  or  weakened  heart  from  the  suddenly  increased  amount 
of  work  thrown  upon  it.  For  this  reason,  as  well  as  on  account  of  the 
•occurrence  in  animals  of  an  arteriosclerotic  condition^  if  the  use  of 
adrenalin  is  long  continued,  the  drug  must  not  be  given  in  too  large 
•doses  or  over  long  periods. 

^  Die  kiinstliche  Blutleere  der  unteren  Korperhalfte,  Arch.  f.  klin.  Chir.,  1909,  Ixxxix, 
1016.  He  applies  it  until  the  pulse  in  the  femoral  artery  just  disappears,  and  has  held  it 
in  place  for  as  long  as  two  hours  and  twenty  minutes  without  deleterious  results. 

2  D.  D.  Jackson  (Prolonged  Persistence  of  Adrenalin  in  the  Blood,  Amer.  Jour,  of 
Thysiology,  1909,  xxiii,  226)  says  adrenalin  does  not  persist  in  the  blood  after  its  visible 
•effects  in  the  rise  of  blood-pressure  have  disappeared.  In  the  dog  adrenalin  disappears 
in  about  one  minute. 

^N.  Waterman  (Arteriosclerosis  after  Injections  of  Adrenalin,  Virchow's  Archiv, 
1908,  cxci,  202)  says  that  research  shows  that  the  arteriosclerosis  induced  in  animals 
^fter  injection  of  adrenalin  closely  resembles  ordinary  arteriosclerosis  in  man. 


88         shock:  causes,  symptoms,  treatment 

Caffein  is  a  vasoconstrictor  of  rapid  action,  which  causes  a  rise  in 
blood-pressure  that  is  maintained  about  one  and  one-half  hours.  It  is 
said  to  act  better  when  the  heart  structure  is  diseased  or  weakened,  as 
in  acute  infectious  diseases,  than  when  it  is  normal.  It  is  useful  in  an 
emergency,  and  may  be  given  in  the  form  of  strong  coffee  by  way  of 
the  rectum,  in  doses  of  2  to  4  ounces.  Caffein  is  otherwise  given  sub- 
cutaneously  in  2  or  3  gr.  doses.  On  account  of  the  poor  solubility 
of  the  alkaloid  in  water  (i  in  45.6  parts),  the  form  ordinarily  used  for 
hypodermic  medication  is  the  freely  soluble  caffein  and  sodium  benzoate 
(N.F.),  which  contains  45  per  cent,  caffein,  and  should  be  given  in 
doses  of  3  to  6  gr.     It  may  be  repeated  in  two  to  four  hours. 

Strychnin  is  the  least  dependable  of  all  the  vasomotor  drugs  of  this 
class.  From  recent  investigations  it  appears  that  its  action  at  best  is 
inconstant,  and  that  a  rise  in  blood-pressure,  through  direct  stimula- 
tion of  the  vasomotor  center,  is  produced  only  when  the  drug  is  given 
in  quantity  approximating  the  toxic  dose.  A  comparatively  safe  ac- 
tive dose  is  -YQ  gr. ;  this  may  be  followed  in  fifteen  minutes  by  -^  gr.,  and 
then  -yq  gr.  given  every  two  hours.  It  must  be  borne  in  mind  that, 
though  no  toxic  symptoms  appear  during  shock,  the  patient  may  be 
taken  with  convulsions,  if  larger  doses  are  given,  as  soon  as  the  condi- 
tion of  shock  disappears,  as  the  result  of  the  cumulative  action  of  the 
drug,  which,  in  the  state  of  shock,  has  not  been  eliminated. 

Alcohol  must  be  considered  here,  for  though  it  is  ordinarily  classed 
as  a  vasodilator,  recent  works  seem  to  show  that  moderate  amounts 
given  by  mouth  or  rectum  induce,  coincident  w^ith  the  peripheral  dila- 
tation, a  constriction  of  the  splanchnic  vessels.  These  findings  bear 
out  the  clinically  often-observed  stimulant  effect  of  alcohol  in  shock. 
It  may  be  given  in  the  form  of  brandy  diluted  with  an  equal  part  of 
water — one  ounce  by  mouth  or  tvvo  ounces  by  rectum. 

The  animal  investigations  by  Crile  show  also  that  the  rapid  action 
of  the  heart  occurring  in  shock  is  not  due — ^in  the  early  stages  at  least — 
to  exhaustion  of  the  organ,  but  rather  to  the  fact  that  the  heart  has  an 
insufficient  quantity  of  blood  to  work  upon.  The  situation  has  its 
parallel  in  the  damage  which  is  done  to  the  engines  of  an  ocean  liner 
going  at  full  speed  which  suddenly  has  her  propeller  lifted  clear  of  the 
water,  and  may  be  compared  with  the  exhausting  futility  of  working 
a  pump  with  no  water  in  the  tube.  He  found  that  if  salt  solution  or 
blood  were  supplied  to  take  the  place  of  the  blood  stagnant  in  the 
splanchnic  reservoir,  the  heart  at  once  began  to  work  more  slowly  and 
forcibly.     We  shall  consider  four  methods  of  supplying  the  needed  fluids: 


TREATMENT  89 

(i)  Emptying  the  peripheral  vessels. 

(2)  Salt  solution  infusion  (hypodermoclysis) . 

(3)  Intravenous  infusion  of  salt  solution. 

(4)  Transfusion  of  blood. 

Rectal  absorption  is  too  slow  to  make  this  route  of  any  value  in 
early  shock.  The  drop  method  may  be  advantageously  employed  in 
continued  shock  or  in  connection  with  other  methods. 

It  has  been  clearly  demonstrated  that  blood  can  be  forced  into 
the  general — so  to  speak,  vital — circulation  from  the  extremities.  The 
vascular  content  of  the  arms  and  legs  is  considerable,  and  elastic  pres- 
sure exerted  on  the  limbs  will  empty  these  peripheral  vessels,  cut  them 
off  in  great  part  from  the  circulation,  and  force  their  content  of  blood 
into  more  vital  channels.  This  is  the  fundamental  principle  of  the 
elastic  suit  of  Crile,  an  arrangement  by  which,  pneumatically,  measured 
elastic  pressure  could  be  exerted  on  the  legs  and  abdomen.  On  ac- 
count of  its  inconvenience  and  complexity  this  appliance  has  not  generally 
been  adopted,  but  the  underlying  principle  can  be  met  to  a  degree  by 
simple  elevation  of  the  lower  portion  of  the  body,  in  the  Trendelenburg 
posture,  by  massaging  the  limbs  and  abdomen,  and  by  tight  bandaging 
of  the  extremities  with  elastic  rubber  or  fabric  bandages  from  toes  to 
groin  and  fingers  to  shoulder.  The  pressure  may  be  graduated;  if  it  is 
so  great  as  nearly  completely  to  shut  off  the  circulation,  the  apparatus 
cannot  be  safely  worn  longer  than  five  minutes.  The  bandages  may 
be  left  in  place,  or  a  tourniquet  may  be  put  on  at  their  upper  limit,  as 
the  groin,  and  the  bandages  removed.  Thus,  after  both  legs  have  been 
emptied,  a  tourniquet  may  be  applied  about  the  abdomen,  at  the  level 
of  the  umbilicus,  and  with  a  pad  over  the  aorta. 

In  cases  of  circulatory  weakness  due  to  hemorrhage,  shock,  or 
other  vasomotor,  conditions  the  injection  of  salt  solution  is  a  valuable 
mode  of  treatment.  When,  however,  the  trouble  is  due  to  heart  failure, 
the  increase  in  the  quantity  of  fluid  means  an  added  strain  upon  the 
heart,  and,  is,  therefore,  contra-indicated. 

Hypodermoclysis  is,  on  the  whole,  the  most  satisfactory  method  of  sup- 
plying fluid  to  the  circulation;  the  procedure  has  already  been  described 
in  the  chapter  on  Thirst  (Chapter  III).  Fully  twenty  minutes  should 
be  allowed  for  the  injection  of  three  pints,  at  a  temperature  of  110°  F. 
Care  should  be  taken  that  the  "fluid  does  not  become  cooled  below 
body  temperature  in  transit  through  the  tube.  There  is  usually  to  be 
noted  a  rapid  improvement  in  the  circulatory  condition  after  its  ad- 
ministration. This  improvement  may,  however,  be  only  temporary, 
and  show  signs  of  wearing  off  at  the  end  of  an  hour,  so  that  one  should 


90         shock:  causes,  symptoms,  treatment 

be  prepared  to  repeat  the  infusion  if  indicated.  It  is  a  mistake  to 
give  too  large  a  dose;  a  safe  and  effective  rule  is  three  pints,  repeated 
hourly  if  indicated.  Hypodermoclysis — ^just  as  transfusion  of  salt  solu- 
tion and  of  blood — is  most  valuable  when  hemorrhage  has  been  an  ele- 
ment in  the  causation  of  shock.  It  is  important,  also,  that  no  fluid  be 
infused  while  there  is  actual  bleeding,  and  care  must  be  exercised  that 
the  volume  and  pressure  of  the  blood-current  is  not  raised  too  high  or 
too  suddenly  where  clotting  has  been  relied  upon  to  stop  hemorrhage. 
Intravenous  infusion  oj  salt  solution  is  being  largely  superseded  by 
hypodermoclysis.  Its  disadvantage  is  in  its  much  slower  and  more 
difficult  technique.  Its  advantage  lies  in  the  immediate  relief  which  it 
gives  to  the  vascular  system.^  On  the  other  hand,  if  the  saline  is  too 
rapidly  infused,  the  blood  taken  into  the  heart  will  be  extremely  di- 
luted, imperfect  aeration  and  dyspnea  will  be  induced,  and  imme- 
diate death  may  occur.  One  of  the  larger  superficial  veins  of  the 
upper  arm  is  usually  chosen — the  basilic  or  cephalic.  This  is  made 
to  stand  out  by  a  loose  tourniquet  applied  above,  and,  aseptically,  it 
is  dissected  out  through  a  longitudinal  incision  about  an  inch  long. 
Two  silk  ligatures  are  passed  under  it.  The  lower  one  is  tied;  be- 
tween the  two  the  vein  is  nicked,  the  end  of  the  cannula  attached  to  the 
tube  from  the  salt  solution  bottle  is  introduced  (taking  care  that  there 
is  no  air  in  the  tube),  and  the  upper  Hgature  tied  once  about  its  tip. 
After  the  bottle  is  emptied  the  cannula  is  slipped  out  and  the  upper 
ligature  drawn  taut,  so  as  to  tie  off  the  proximal  end  of  the  vessel.  The 
skin  is  sewed  and  a  sterile  dressing  applied.  There  are  disadvantages 
beyond  those  of  technique,  as  shown  in  the  following  case: 

A  young  woman,  acrobat  by  profession,  was  seen  in  a  state  of  severe  shock 
from  some  intra-abdominal  condition.  An  immediate  celiotomy  was  per- 
formed and  simultaneously  an  intravenous  infusion  of  salt  solution  made. 
The  patient  recovered,  but  the  incision  for  the  infusion  became  infected 
and  left  a  scar.  She  threatened  to  institute  suit  against  the  operator,  on  the 
ground  that  the  infusion  was  performed  without  her  permission,  and  that  the 
scar  was  unsightly  and  thus  interfered  \^dth  her  earning  capacity  as  an  acrobat. 

For  the  transfusion  of  blood,  see  p.  68,  et  seq. 

Anemia  of  the  vasomotor  center  will  be  combatted  by  the  measures 
already  detailed  for  the  purpose  of  equalizing  and  stimulating  the 
circulatory  system.     It  is  rather  important  that  the  patient  lie  in  bed 

^  T.  Meissl  (Wert,  der  Intra-venosen  Adrenalin-Kochsalzinfusionen,  Wien.  klin. 
Woch.,  1908,  xxi,  835)  says  that  the  result  is  transient  and  may  be  repeated,  thus 
stimulating  the  heart  action  and  the  vasomotor  center  until  the  organism  can  bring  up  its 
reserves.     The  prospects  are  best  in  acute  anemia. 


TREATMENT  gi 

without  a  pillow,  and  that  the  foot  of  the  bed  be  raised  on  blocks.  This 
position  facilitates  the  return  of  the  blood  from  the  extremities  and 
increases  the  quantity  supplied  the  brain.  Alcohol  is  of  some  use  in 
dilating  the  cerebral  vessels.  If  imperfect  aeration  of  the  blood  is  an 
element,  as  evidenced  by  cyanosis  of  the  lips  and  under  the  finger-nails, 
inhalation  of  oxygen  is  indicated.  If  shock  has  developed  before  the 
patient  has  recovered  from  the  anesthetic  and  the  breathing  has  become 
rapid  and  shallow,  oxygenation  of  the  blood  may  be  improved  and 
elimination  of  the  anesthetic  assisted  by  the  use  of  artificial  respiration  for 
a  short  period,  or  atropin  may  be  given  to  stimulate  the  respiratory  center. 

The  treatment  of  intrinsic  cardiac  exhaustion  resolves  itself  prac- 
tically into  the  consideration  of  the  application  of  digitalis;  the  stagna- 
tion of  blood  in  the  vessels  of  the  splanchnic  area  and  the  resulting 
lowering  of  blood-pressure  in  the  general  circulation  having  been  com- 
batted,  so  far  as  possible  by  the  measures  already  suggested,  a  suf- 
ficient amount  of  fluid  having  been  supplied  by  means  of  infusion  or 
transfusion  for  the  heart  to  work  upon,  and  anemia  of  the  cardio- 
vascular centers  having  been  to  some  degree  overcome  by  these  and 
other  measures.  Digitalis  induces,  by  direct  action  upon  the  heart, 
a  slower  and  more  complete  emptying  of  the  ventricles;  this  increases 
the  volume  of  blood  in  active  circulation,  and  consequently  raises  the 
blood-pressure,  and,  by  inducing  a  better  circulation  in  the  coronaries, 
improves  the  nutrition  of  the  heart-muscle  itself.  There  is  a  secondary 
action  on  the  vessels,  consisting  chiefly  in  the  constriction  of  the  splanchnic 
arteries  and  an  accompanying  dilatation  of  the  peripheral  vessels,  in- 
cluding those  of  the  brain. 

Given  by  mouth,  digitalis  is  slowly  absorbed,  taking  from  twelve 
to  thirty-six  hours  before  its  action  becomes  evident.  Moreover,  it  is 
cumulative  in  action,  and  for  that  reason  it  is  liable  to  be  poisonous 
when  given  in  large  doses.  It  is  irritating  also  to  the  mucous  mem- 
brane of  the  stomach.  On  account  of  its  cumulative  action,  it  should 
be  withdrawn  gradually  after  the  indication  for  its  use  has  disappeared. 
An  overdose  is  shown  by  an  abnormal  slowing  of  the  pulse.  The 
digitalis  of  commerce  varies  markedly  in  strength  and  may  be  prac- 
tically inert.  One  should  use  a  standardized  tincture  of  reliable  origin; 
the  active,  isolated  parts  and  derivatives,  of  which  there  are  many  in 
the  market  (digitalinum  verum,  digitalin,  digitoxin,  digalen,'  soluble 
digitalone,  etc.),  are  clinically  uncertain  and  are  apt  to  be  unstable. 
Insomuch   as    absorption  by   mouth    is    probably   interfered    with   in 

^  Jour.  Am.  Med.  Assoc,  Sept.  ii,  1909,  liii,  869. 


92  shock:  causes,  symptoms,  treatment 

shock,  the  drug  had  best  be  given  hypodermically.  This  method  en- 
forces certain  absorption,  prompt  action,  and  does  away  with  gastric 
irritation. 

A  reliable  preparation  of  strophanthin  (Boehringer  or  Burroughs, 
Wellcome  &  Co.),  given  intravenously,  is  sometimes  dramatic  in  its 
stimulating  effect  in  profound  cardiac  exhaustion.^  It  is  given  from 
a  hypodermic  needle  into  a  vein  of  the  elbow-flexure  in  a  dose  of  gig- 
gr.,  to  be  repeated  in  an  hour  if  necessary. 

Slapping  the  diaphragm  and  dilating  the  anal  sphincter  should  be 
resorted  to  if  necessary.  The  application  of  the  faradic  current  to  the 
diaphragm  is  indicated  if  apparatus  is  at  hand.  Atropin  should  be  given 
subcutaneously  to  stimulate  respiration.  Amy!  nitrite  should  be  volatil- 
ized under  the  patient's  nostrils.  This  increases  the  cerebral  circula- 
tion. Rapidly  acting  stimulants,  such  as  ammonium  carbonate,  camphor, 
ether,  or  aromatic  spirits  of  ammonia,  may  be  given  subcutaneously. 

Massage  of  the  Heart. — If  the  patient  collapses  on  the  table  dur- 
ing a  celiotomy,  especially  under  chloroform  anesthesia,  and  other 
means  of  resuscitation  fail  to  elicit  any  response,  direct  massage  of  the 
heart  may  be  justified.  The  heart  is  grasped  through  the  diaphragm, 
the  left  hand  being  inserted  through  an  incision  above  the  umbilicus, 
the  ventricles  are  squeezed  rhythmically  between  the  fingers,  or  the 
heart  is  pushed  against  the  front  wall  of  the  chest.  The  massage  must 
be  kept  up  for  a  long  time,  supporting  the  spontaneous  contractions,  or 
otherwise  the  heart's  action  will  flag  again.  In  some  cases  fifteen  min- 
utes elapse  before  the  heart  responds  to  the  massage.  Artificial  respira- 
tion should  be  maintained  simultaneously,  with  possible  tracheotomy  or 
intubation,  to  insure  the  rhythmic  supply  of  oxygen  to  the  lungs.  The 
pelvis  should  be  raised  and  the  abdomen  compressed  to  aid  in  increas- 
ing the  blood-pressure  by  overcoming  the  paralysis  of  the  vasomotor 
mechanism.  This  procedure,  though  rarely  used  in  this  country,  has 
been  applied  with  some  reported  success  in  England. 

M.  V.  Cacko\ic  (Ueber  direct  Massage  des  Herzens  als  Mittel  zur  Wiederbelebung, 
Archiv  f.  klin.  Chir.,  1909,  IxxxA'iii,  910)  reports  a  case  of  death  under  chloroform 
in  a  boy  nine  years  old,  in  which  the  heart  was  exposed  and  massaged.  He  found  45 
cases  in  the  Mterature  and  analyzes  the  details  and  results.  ^Massage  was  practised  for 
resuscitation  in  17  cases,  9  of  which  completely  recovered.  In  the  rest  the  heart  failed 
again  after  working  for  a  longer  or  shorter  inters'al.  Iii  all  but  5  of  the  cases  the  syncope 
occurred  under  an  anesthetic.  The  best  results  were  obtained  by  massage  applied  from 
below  the  diaphragm.  It  failed  in  other  cases  with  the  transdiaphragmatic  technique. 
The  outcome  was  better  the  earlier  after  the  syncope  the  massage  was  undertaken.  The 
first  five  minutes  gave  the  most  cases  of  success,  while  the  massage  failed  constantly  if 
ten  minutes  had  elapsed  after  the  onset  of  the  syncope  before  the  massage  was  commenced. 

^  A.  K.  Stone,  Boston  'Sled,  and  Surg.  Jour.,  1909,  clxi,  586. 


MASSAGE    OF    THE    HEART  93 

The  prospects  are  more  favorable  for  direct  massage  of  the  heart  when  the  syncope  is  of 
circulatory  rather  than  respiratory  origin. 

Pike,  Guthrie,  and  Stewart  (General  Conditions  Affecting  Resuscitation  and  the  Resus- 
citation of  the  Blood  and  Heart,  Jour.  Exp.  Med.,  Lancaster,  1908,  x,  371)  state  that 
resuscitation  of  the  heart  may  sometimes  be  accomplished  by  extrathoracic  massage  and 
artificial  respiration,  but  only  during  the  period  that  the  heart  continues  to  beat;  direct 
massage  of  the  heart  is  the  most  certain  method  at  hand  for  resuscitation.  A  proper  blood- 
pressure  is  necessary  for  its  continued  activity.  Anesthesia  and  hemorrhage  make  resus- 
citation more  difficult  than  asphyxia  alone. 

White  (Maryland  Med.  Jour.,  1908,  li,  380):  Child  of  twelve  years  stopped  breathing 
under  chloroform.  Artificial  respiration  and  other  means  of  no  avail.  Abdomen  incised 
and  subphrenic  massage  instituted  at  rate  of  25  per  minute.  Heart-beat  reappeared 
feebly  at  end  of  one  minute,  then  regularly.  Convulsions  appeared  and  child  died  twenty 
hours  after  operation. 

Mocquot  (La  Reanimation  du  Coeur,  Revue  de  Chir.,  Paris,  1909,  xxix,  696;  924;  1184) 
reviews  all  cases  on  record  and  adds  unpublished  cases.  Best  mode  of  access  is  through 
the  abdomen.  Complete  success  in  9  cases  out  of  22.  Two  complete  successes  with 
massage  through  the  chest -wall.  The  diaphragm  may  be  too  taut.  In  this  case  it  should 
be  relaxed  by  raising  the  pelvis.  The  heart  is  sometimes  so  flabby  that  it  cannot  be  felt 
through  the  diaphragm,  but  after  a  few  compressions  it  regains  its  consistency  under  the 
massage.     If  there  is  effusion  into  the  pericardium  the  chances  of  success  are  very  slight. 

It  is  probably  not  necessary  to  take  hold  of  the  heart  itself  to  apply  effectual  massage. 
It  is  easier  and  more  effectual  merely  to  compress  the  ventricle  against  the  wall  of  the 
thorax  by  means  of  the  hand  introduced  flat  under  the  diaphragm  behind  the  heart,  with- 
out incising  it.  While  massage  is  being  applied,  artificial  respiration  should  be  kept  up 
to  relax  the  diaphragm.  The  Sylvester  method  interferes  with  the  massage.  The  best 
technique  is  by  direct  insufflation  through  a  tube.  The  rhythm  of  the  massage  should  be 
about  60  a  minute.  The  best  success  has  been  in  chloroform  syncope.  The  best  chance 
exists  when  it  is  commenced  not  later  than  fifteen  minutes  after  the  arrest  of  the  heart. 
Adrenahn  is  a  valuable  aid  in  stimulating  the  heart  to  contract,  associated  with  massage. 

In  asphyxia  it  is  more  difficult  to  revive  the  heart  action  than  in  syncope.  Besides 
massage  and  insufflation,  which  suffice  for  the  ordinary  white  syncope,  intravenous  injec- 
tions of  adrenalin  and  transfusion  are  required. 

In  shock  persisting  over  any  length  of  time  it  becomes  important 
to  administer  nourishment  regularly.  Usually  the  rectal  route  is  the 
one  selected,  and  a  nutritive  enema  (see  Chapter  XII)  may  be  re- 
peated every  two  hours.  A  good  stimulating  enema  in  practice  is  the 
following : 

I^.     Black  coffee ovj; 

Brandy o  ij ; 

Tr.  digitalis W^', 

Ammon.  carb gr.  xx; 

Tr.  opii nix. — M. 

At  the  same  time  it  must  be  seen  to  that  the  patient's  comfort  is  looked 
out  for,  his  tongue  kept  moist,  and  distention  of  the  bladder  a^•oided. 
By  all  means  possible  the  circulation  must  be  efficiently  maintained 
until  the  vasomotor  centers  have  recovered  from  their  anemia  and 
exhaustion. 


CHAPTER  VIII 
COMA:  DIABETIC;  UREMIC   COLLAPSE;  SUDDEN  DEATH 

The  development  of  coma  after  an  operation  is  infrequent,  but 
when  it  occurs,  it  is  usually  of  serious  portent.  It  may  follow  so  closely 
upon  the  operation  that  the  patient  never  regains  consciousness,  or  it 
may  take  some  days  to  develop.  We  shall  consider  three  forms — the 
diabetic,  uremic  (including  puerperal  eclampsia),  and  simple  collapse. 
It  must  not  be  forgotten  that  a  comatose  condition  may  be  due  to  an 
overdose  of  morphin  or  the  action  of  a  moderate  dose  upon  a  patient 
with  an  idiosyncrasy. 

It  was  formerly  one  of  the  traditions  of  surgery  that  sugar  in  the 
urine  was  an  absolute  contra-indication  to  anesthetization.  Nowadays,, 
unless  we  are  dealing  with  an  undoubted  and  progressing  case  of  dia- 
betes mellitus,  it  is  generally  considered  that  with  the  exercise  of  proper 
precautions  the  risk  is  slight. 

The  patient  should  be  properly  prepared  by  dieting  during  as  long 
a  period  as  the  nature  of  the  surgical  indication  will  allow,  so  that  the 
sugar  content  of  the  urine  is  diminished  as  much  as  possible.  One 
should  take  care,  however,  that  the  patient  is  not  starved.  The  anes- 
thetic should  be  carefully  and  evenly  administered.  The  period  of 
anesthetization  should  be  as  short  as  possible.  Chloroform  is  contra- 
indicated  on  account  of  its  effect  on  fat  metabolism  in  the  liver. 
Usually  in  the  case  of  middle-aged  glycosurics,  who  have  been  main- 
taining an  almost  constant  output  of  sugar  for  some  years  with  only 
slight  disturbance  to  health,  with  these  precautions  little  need  be  feared, 
although,  if  the  sugar  percentage  is  high,  a  protracted  etherization  may 
disturb  the  metabolic  balance  and  lead  to  fatal  results. 

In  undoubted  diabetes,  especially  in  those  cases  where  the  sugar 
cannot  be  reduced  by  dieting,  operations  should  be  put  off  as  long  as 
possible,  and  their  performance  should  be  as  rapid  as  the  surgeon's 
technique  will  allow.  Carbohydrates  should  be  administered  after  the 
operation  with  the  hope  of  staving  off  coma.  There  is  no  question 
but  that  the  postoperative  administration  of  carbohydrates  in  reason- 
able amounts  assists  the  healing  of  wounds  in  diabetics. 

When  the  diabetic  cotna  supervenes,  it  may  come  on  shortly 
after  operation,  so  that  the  patient  who  has  been  under  ether  for  twenty 
minutes,  to  allow  of  the  excision  of  a  carbuncle,  may  be  dead  in  from 

94 


UREMIC    COMA 


95 


four  to  tAvelve  hours.  Usually  it  takes  two,  three,  or  more  days  for 
coma  to  develop,  and  the  danger  is  past  if  it  does  not  make  its  appear- 
ance within  a  week.  The  urine  and  the  sugar  percentage  rapidly  in- 
crease, the  patient  becomes  restless  and  mentally  disturbed,  and  the 
breathing  and  pulse-rate  ascend.  Then  coma  sets  in,  the  face  becomes 
pallid,  the  body  and  extremities  cold,  and  the  temperature  falls  to 
subnormal.  There  is  deep  sighing  respiration,  and  the  urine  decreases 
in  quantity  and  shows  the  presence  of  acetone. 

Recovery  from  postoperative  diabetic  coma  is  rare.  The  usual 
treatment  of  coma  in  diabetes  should  be  instituted.  The  patient's 
bowels  should  be  emptied  and  injections  of  sodium  bicarbonate  (6  drams 
to  the  pint)  should  be  given  under  the  skin,  and  fluids,  alkaline  if  well 
borne,  should  be  forced.^ 

Uremic  coma  after  operation  may  be  due  to  several  causes. 
Among  these  we  have  to  consider  eclampsia  in  pregnant  women,  uremia 
in  patients  with  chronic  Bright's  disease,  anuria,  dependent  upon  a  tying 
in  of  the  ureter  by  mistake,  and  finally  uremia  in  cases  where  an  only 
kidney  has  been  removed  or  a  nonfunctionating  kidney  left  behind. 

Eclampsia  rarely  occurs  primarily  after  an  operation.  Oftentimes 
the  uterus  may  be  emptied  by  operative  means  as  a  result  of  eclampsia, 
and  in  this  case  after  operation  there  is  a  decided  improvement,  or  else 
the  eclamptic  condition  continues  and  the  patient  dies.  Rarely  after 
operations  upon  pregnant  women  primary  eclampsia  may  be  induced. 

In  middle-aged  and  elderly  persons  with  impaired  renal  functions 
ether  should  always  be  used  with  circumspection.  A  prolonged  anes- 
thetization in  persons  presumably  normal  may  be  followed  by  the 
exhibition  of  casts  and  albumin  in  the  urine.  In  these  patients  after 
an  operation  there  may  be  a  marked  increase  in  the  amount  of  albu- 
min, renal  excretion  may  gradually  diminish  in  quantity  and  quality, 
and  a  comatose  condition  may  develop.  After  a  varying  number  of 
hours  or  days  of  semiconsciousness  the  patient  dies.  Not  only  is  this- 
to  be  feared  in  persons  with  Bright's  disease,  but  is  especially  to  be 
guarded  against  in  elderly  prostatics  who  have  been  carried  along  for 
an  extended  period  on  catheterization.  In  these  cases  one  is  apt 
to  find  a  small,  thickened,  corrugated  bladder,  markedly  dilated  ure- 
ters, dilated  renal  pelvis,  all  containing  more  or  less  pus,  and  a  notably. 
decreased  secreting  substance  in  the  kidney.     These  cases  after  operation 

^  Becker  (Deutsche  med.  Woch.,.1894,  xx,  359;  380;  404)  reported  3  fatalities  following 
anesthesia  in  diabetic  patients,  in  which  acetonuria  was  present  at  the  time  of  operation. 
He  reported  other  cases  in  which  death  followed  anesthesia  in  diabetic  patients.  He  was 
led  to  believe,  therefore,  that  diabetic  patients  were  liable,  owing  to  some  change  in  the 
process  of  metabolism,  to  pass  into  a  condition  of  coma  and  death. 


g6         coma:  diabetic;  uremic,     collapse;  sudden  death 

may  react  poorly,  their  urinary  secretion  may  diminish  steadily,  and 
the  patient  sink  from  coma   to  death. 

Rufus  HalP  considers  that  patients  with  fatty  hearts  are  liable  to  have 
suppression  of  urine  after  sections.  In  one  of  his  cases,  in  which  this  condition 
was  diagnosed,  he  performed  hysterectomy.  In  the  first  nineteen  hours  after 
the  operation  she  secreted  24  ounces  of  urine,  heavily  loaded  with  albumin. 
During  the  next  seventy-four  hours  there  was  almost  complete  suppression. 
Coma  became  marked,  but  it  was  promptly  relieved  by  steam  baths  and  cathar- 
sis. At  the  end  of  seventy-four  hours  she  was  catheterized,  and  ij  ounces  of 
urine  obtained.     From  this  onward  she  improved. 

Hall  also  operated  on  a  patient,  aged  sixty-three,  and  performed  abdominal 
hysterectomy  for  cancer  of  the  uterus.  Her  arteries  were  atheromatous. 
Before  the  operation  there  was  a  diminished  quantity  of  urine,  but  no  albumin 
nor  casts.  Chloroform  was  administered.  During  the  first  twelve  hours 
she  secreted  5  ounces  of  urine,  heavily  loaded  with  albumin.  The  urine  gradu- 
ally decreased  in  quantity,  until  at  the  end  of  fifty  hours  there  was  scarcely  any 
secreted.  She  remained  in  a  condition  bordering  on  coma  for  two  days. 
She  then  commenced  to  secrete  from  6  to  9  ounces  of  urine  in  twenty-four 
hours.  This  improvement  lasted  for  more  than  a  week;  then  there  was  a 
sudden  suppression  and  she  was  profoundly  comatose  for  ten  or  twelve  hours. 
At  the  end  of  the  third  week  following  the  operation  she  had  suppression  for 
the  third  time.  It  lasted  two  days.  She  recovered,  and  the  albumin  entirely 
disappeared. 

Uremia  may  be  the  result  of  anuria  caused  by  some  surgical  acci- 
dent. A  ureter  may  be  cut  or  tied  off  accidentally,  and  cases  are  on 
record  where  both  ureters  have  been  accidentally  divided  during  hys- 
terectomy. Then,  again,  a  nephrectomy  may  be  performed  without 
first  ascertaining  if  the  patient  has  another  functionating  kidney.  In 
these  cases  the  condition  is  apt  to  develop  rapidly  and  death  may 
occur  within  twenty-four  hours.  The  temperature  falls  to  subnormal, 
there  may  be  profuse  perspiration,  but  the  skin  soon  becomes  dry. 
There  are  vomiting  and  contracted  pupils.  There  have  been  cases, 
however,  that  have  lived  for  a  week  or  ten  days  before  coma  ends  in  death. 
In  all  cases  where  there  is  suspicion  of  anuria  being  caused  by  ureteral 
obstruction  the  abdomen  should  be  reopened  and  an  attempt  made  to 
remedy  the  condition.  The  general  treatment  of  these  cases  consists 
in  sweating  the  patient  profusely  by  means  of  hot  air  and  a  tent,  by  hot 
packs,  the  use  of  salt  solution  subcutaneously,  or  by  rectum,  or  under 
the  breast,  and  the  administration  of  digitalis  and  potassium  acetate; 
pilocarpin  may  also  be  used,  as  well  as  dry  cupping,  but  pilocarpin 
should  only  be  used  in  strong  patients,  gr.  ^  every  four  hours,  three  to 

^  Am.  Jour.  Obst.,  1898,  ii,  679.     Quoted  by  McKay,  Section  Cases,  N.  Y.,  1905, 486. 


SUDDEN    DEATH  97 

six  doses.  Patients  with  nephritis  should  always  be  anesthetized  with 
care,  using  a  minimum  amount  of  ether. 

For  postoperative  nephritis,  see  Chapter  XVIII,  p.  169. 

Sometimes  a  comatose  condition  after  an  operation  will  represent 
simple  collapse  on  the  part  of  the  patient.  In  this  case  the  coma  is 
not  attended  by  the  symptoms  which  we  should  expect  to  find  in  dia- 
betes and  uremia.  The  pulse  is  somewhat  rapid  and  weak,  but  the 
temperature  is  about  normal  and  the  color  is  fair.  Ordinarily  collapse 
and  shock  are  classed  together.  Collapse  may  occur,  however,  in 
nervous  patients  particularly,  on  comparatively  slight  provocation. 
Under  these  circumstances  the  milder  method  of  treatment  suggested 
in  the  last  chapter  will  be  of  avail  in  restoring  the  patient. 

SUDDEN  DEATH 

It  sometimes  happens  in  the  practice  of  the  most  experienced  sur- 
geons that  a  patient  who  is  apparently  progressing  favorably,  without 
complications,  suddenly  dies.  Death  may  occur  within  a  matter  of 
minutes,  no  premonitory  signs  having  appeared.  Usually  the  diagnosis 
is  made  after  death,  and  then,  in  default  of  an  autopsy,  with  some 
degree  of  uncertainty.     To  the  friends,  explanation  is  usually  difficult. 

The  causes  which  may  lead  to  sudden  death  are  considered  under 
their  respective  headings.  The  recent  article  on  the  subject  by  John 
Babst  Blake^  is  worth  quoting  at  length : 

"  Emotion  is  very  often  a  potent  factor  in  originating  the  processes 
w^hich  result  in  sudden  death. 

"  It  is  obvious,  therefore,  that  emotion,  exercise,  and  exertion  are 
very  frequently  the  exciting  cause  of  sudden  death,  and  a  moment's 
consideration  reveals  the  fact  that  these  are  precisely  the  conditions 
preceding  and  accompanying  the  average  surgical  operation.  The 
apprehension  and  fright  are  very  obvious,  while  the  effect  of  the  anes- 
thetic upon  pulse,  respiration,  skin,  and  kidneys  is  precisely  that  of 
moderate  exercise;  furthermore,  the  effects  of  long-continued  and  very 
serious  surgical  interference  are  again  analogous  to  very  severe  exertion. 
We  have,  therefore,  in  the  routine  of  modern  surgery,  reproduced  with 
considerable  accuracy  the  conditions  under  which  a  majority  of  sudden 
deaths  occur.  Is  it  not  a  fair  inference  that  many  of  the  all-too-frequent 
deaths  said  to  be  due  to  anesthesia  are  simply  coincidental,  and  would 
have  occurred  with  equal  certainty  under  any  other  procedure  which 
reproduced  these  precise  conditions? 

"  Sudden  deaths  before,  during,  or  immediately  following  operation 

^  Ann.  Surg.,  1909,  1,  49. 
7 


98         coma:  diabetic;  uremic,     collapse;  sudden  death 

are  too  common,  and  undoubtedly  many  occur  that  are  not  reported. 
The  writer  has  been  informed  of  6  in  the  past  year  in  which,  with 
perhaps  one  exception,  neither  the  anesthetic  nor  the  operation  seemed 
a  sufi&cient  cause.  It  is  notorious  to  those  who  concern  themselves 
with  anesthesia  that  ether  and  chloroform  are  frequently  blamed  for 
catastrophes  for  which  they  are  not  wholly,  or  at  times  even  in  part, 
responsible. 

"The  more  we  know  of  the  real  nature  of  these  deaths  the  better 
shall  we  be  able  to  avoid  them.  Certain  facts  stand  forth.  We  cannot 
yet  predict  with  any  certainty  the  individuals  who  are  doomed  to  sudden 
death,  nor  the  time  of  its  occurrence,  but  we  do  know  many  of  the  patho- 
logic conditions  which  predispose  to  it  and  the  circumstances  under 
which  it  most  frequently  occurs.  In  endeavoring  to  guard  against  it 
we  must  remember: 

"  (i)  The  comparative  frequency  of  status  lymphaticus.  At  least  8 
cases  have  come  to  medicolegal  autopsy  as  the  result  of  sudden  death 
in  Boston  within  the  past  year,  and  in  the  experience  of  only  two  medical 
examiners.  Another  has  been  withheld  from  operation  by  the  skilful 
diagnosis  of  a  physician;  another  died  shortly  after  a  simple  circumci- 
sion. It  is  believed  that  the  diagnosis  can  often  be  made  in  advance 
by  attention  to  the  possible  presence  of  a  thymus,  bowing  of  the  femurs, 
a  thick,  short  neck,  and,  in  men,  pubic  hair  of  the  female  type.  Of 
the  8  cases  upon  which  autopsy  was  done,  6  died  almost  instantly  and 
2  some  hours  after  a  slight  injury  was  received. 

"  (2)  The  invariable  necessity  for  a  more  thorough  and  complete 
physical  examination  and  personal  history  before  operation  eVen  of  a 
minor  character. 

"  (3)  The  importance  of  diminishing  to  a  minimum  pre-anesthetic 
fright,  apprehension,  and  intense  emotion  for  the  sake  of  the  patient's 
safety  as  well  as  comfort.  (Dr.  Crile  has  reported  an  admirable  method 
of  doing  this  in  thyroid  cases.) 

"  (4)  The  very  great  importance  of  complete  histories  and  autopsies 
in  every  case  of  sudden  death,  an  end  which  can  be  best  attained  by 
securing  the  active  cooperation  of  medical  examiners  and  coroners' 
physicians. 

*'  (5)  The  necessity  of  the  careful  report  of  every  case  of  operative 
sudden  death,  even  if  no  autopsy  is  obtained,  by  the  surgeon  in  charge 
of  the  case.  It  does  not  seem  essential  that  such  reports  should  be 
originally  presented  to  the  world  at  large,  but  they  might  well  be  made 
to  a  small  committee  of  this  Society,  and  by  them  examined  and  analyzed 
and  the  essential  facts  brought  to  the  attention  of  the  medical  public." 


CHAPTER  IX 

THROMBOPHLEBITIS;    PULMONARY    EMBOLISM;    PYLE- 
PHLEBITIS; SUBDIAPHRAGMATIC  ABSCESS 

THROMBOPHLEBITIS 

Thrombophlebitis  of  the  veins  of  the  pelvis  and  extremities  occurs 
from  time  to  time  after  confinements  and  cehotomies.  It  is  especially 
common  after  operations  upon  the  uterus  and  adnexa  and  in  operations 
about  the  rectum.  Although  thrombophlebitis  in  itself  is  a  trouble- 
some and  not  particularly  serious  complication,  its  occurrence  must 
always  be  viewed  with  anxiety  on  account  of  the  potentiality  that  exists 
in  every  thrombus  to  become  an  embolus.  It  commonly  attacks  the  veins 
of  the  calf  and  thigh,  and  more  usually  the  left  than  the  right,  and  in 
cases  of  this  sort  if  the  patient  lies  quietly  in  bed  the  prognosis  is  good. 
After  operations  about  the  uterus  thrombosis  is  set  up  in  the  veins  of 
the  broad  ligament.  If  the  process  extends  along  the  uterine  veins  to 
the  iliac  or  femoral  vessels,  or  along  the  ovarian  vein  to  the  vena  cava, 
the  prognosis  is  serious,  on  account  of  the  great  facility  with  which  clots 
may  gain  entrance  to  the  vena  cava  and  so  be  carried  to  the  pulmonary 
vessels.  Cases  are  reported  following  appendectomy,^  as  well  as  opera- 
tions upon  the  female  pelvic  organs,^  and  after  delivery.^ 

Thrombosis  occurs  usually  between  the  tenth  and  twentieth  day. 
It  is  most  apt  to  occur  in  debilitated  or  anemic  subjects,  those  who  have 
suffered  from  profuse  and  prolonged  menorrhagia  due  to  the  presence 
of  a  submucous  fibroid,  or  those  who  have  been  subjected  to  a  pro- 
longed operation. 

Its  etiology  has  been  the  subject  of  discussion.  It  is  generally 
considered  that  it  is  the  result  of  sepsis,  and  that  it  represents  a  defen- 
sive action  on  the  part  of  the  organism  against  infection.  Sometimes 
a  clot  which  forms  in  the  ordinary  course  of  the  obliteration  of  a  vessel 
behind  a  ligature  will  become  infected  from  wound  sepsis  and  will  dis- 
integrate, or  particles  may  be  carried  in  the  circulation  to  other  points 
and  there  set  up  thrombosis  anew,  or  in  cases  of  stitch-abscesses  infection 

^  SarloH,  Gaz.  deg.  Osp.,  1909,  121. 
2  Bland-Sutton,  Lancet,  1909,  i,  147. 
^Hofmeier,  Cent.  f.  Gyn.,  1909,  xxxiii,  21. 

99 


ICX)  THROMBOPHLEBITIS — SUBDIAPHRAGMATIC   ABSCESS 

may  spread  to  the  femoral  and  iliac  vessels  along  branches  of  the  super- 
ficial and  deep  epigastric  veins.  The  phlebitis  is  usually  secondary  to 
the  septic  thrombus,  which  communicates  infection  to  the  wall  of  the 
vein  in  which  it  lies. 

Large  varicosities  on  the  lower  extremities  afford  a  predisposing 
cause  for  thrombophlebitis.  In  a  number  of  cases  autopsy  showed 
that  an  embolus  in  the  pulmonary  artery  came  from  a  fresh  coagulum 
in  a  varicose  vein  of  the  leg.^ 

Embolism  rarely  comes  on  imtil  the  third  week  after  the  operation, 
and  is  not  to  be  expected  after  six  weeks  have  elapsed.  This  period 
represents  the  time  during  which  the  clot  is  brittle  and  likely  to  disin- 
tegrate. Separation  of  a  portion  of  a  clot  is  apt  to  be  preceded  by  some 
unusual  effort,  such  as  getting  out  of  bed  for  the  first  time  after  opera- 
tion or  straining  during  defecation. 

Symptoms. — The  blood-clots  that  ordinarily  organize  in  the  ves- 
sels of  the  broad  ligament  after  pelvic  operations  offer  no  symptoms 
to  attract  attention  so  long  as  they  remain  sterile.  If,  however,  a  clot 
becomes  infected,  diagnosis  wiU  usually  make  itself  evident  on  vaginal 
examination  by  the  presence  of  tenderness  and  swelling  on  the  alTected 
side.  In  addition  to  this  spot  of  tenderness  in  the  iliac  region  the  leg 
on  the  same  side  may  be  swollen  and  painful.  Usually  the  pain  will 
start  in  the  calf  of  the  leg,  the  pulse  rise  to  120,  and  the  tem- 
perature to  101°  or  102°,  and  there  may  be  a  mild  initiatory  chill. 
The  whole  limb  may  become  so  swollen  and  excessi\-ely  painful  that  the 
patient  will  not  allow  it  to  be  moved.  The  infected  vessels  will  stand 
out  like  cords  to  palpation,  and  their  course  will  be  marked  by  a  red 
line  upon  the  skin  over  them.  The  phlebitis  may  occur  on  the  side 
upon  which  the  operation  was  performed,  on  the  opposite  side,  or  upon 
both  sides.  The  acute  symptoms  gradually  subside,  and  it  will  be 
three  weeks  or  a  month  before  the  patient  will  be  able  to  set  foot  to  the 
ground.  She  usually  carries  for  many  months  after  recovery  evidences 
of  the  condition,  in  the  shape  of  edema  or  varicose  veins  of  the  leg  and 
ankle. 

Prophylaxis  against  thrombophlebitis  should  always  be  an  import- 
ant consideration  in  the  after-treatment,  particularly  of  gynecologic  cases. 
The  heart  action  should  not  be  allowed  to  become  weak.  Raising 
the  foot  of  the  bed  in  the  Trendelenburg  position  will  lessen  the  accumu- 
lation of  blood  in  the  pelvic  veins  and  will  tend  to  stimulate  the  vital 
centers.  The  patient  should  not  be  allowed  to  lie  upon  her  back  for 
any  long  period  of  time  without  changing  her  position.     She  may  be 

^  A.  Fraenkel,  Archiv  f.  klin.  Chir.,  igoS,  Ixxxvi,  531. 


PULMONARY    EMBOLISM  lOI 

given  breathing  exercises  every  hour;  the  arms  and  hmbs  should  be 
elevated  frequently,  and  the  intestinal  functions  started  early.  Fluids 
by  mouth,  rectum,  and  subcutaneously  will  reduce  the  tendency  to 
thrombosis.  An  excessive  milk  diet  should  not  be  allowed  on  account 
of  the  calcium  which  milk  contains.  If,  however,  sodium  citrate  is 
added  to  the  milk  in  the  proportion  of  2  gr.  to  the  ounce,  this 
disadvantage  will  be  overcome.  The  following  prescription  may  be 
employed,  and  one  teaspoonful  added  to  the  ounce  of  milk: 

I^.     Sodium  citrate gr.  xlviij; 

Oil  of  peppermint iTjjij; 

Distilled  water oiv. — ^M. 

Treatment. — Absolute  rest  in  bed  for  at  least  five  weeks  must  be 
enjoined.  The  patient  must  be  moved  as  little  as  possible,  and  getting 
in  and  out  of  bed  should  be  absolutely  forbidden.  This  is  on  account 
of  the  grave  danger  of  the  detachment  of  a  portion  of  the  clot.  For  the 
same  reason,  an  active  purge  should  never  be  given,  but  enemas  em- 
ployed instead  when  called  for.  Over  the  region  of  the  pain  hot  applica- 
tions should  be  made.  The  foot  and  leg  should  be  wrapped  in  a  thick 
layer  of  absorbent  cotton,  the  foot  should  be  elevated  upon  a  soft  pillow, 
and  movements  of  the  foot  and  leg  should  be  prohibited  by  means  of 
sand-bags  placed  on  either  side.  Belladonna  ointment  may  give  relief. 
Morphin  will  sometimes  be  necessary.  Pressure  from  the  bed-clothes 
should  be  relieved  by  means  of  a  cradle  placed  over  the  leg.  Massage 
of  the  limb  in  every  sense  should  be  strictly  avoided.  Operation  has 
been  performed  for  the  removal  of  a  thrombus.^ 

PULMONARY  EMBOLISM 

Pulmonary  embolism  is  practically  always  consecutive  to  throm- 
bosis in  the  deep  epigastric  or  pelvic  veins  and  in  the  veins  of  the  lower 
extremities  or  in  the  mesenteric  veins,  frequently  following  operation. 
Injury  to -the  vessel  or  changes  in  the  blood  sufficient  to  cause  clotting 
at  any  particular  point  may  be  followed  by  a  dislodgment  of  the  entire 
clot  or  of  a  small  portion,  which  may  be  broken  off  and  carried  away  in 
the  blood-stream.  When  this  happens,  it  is  carried  by  the  blood-cur- 
rent until  it  reaches  a  vessel  which  is  too  small  for  it  to  pass  through. 
As  postoperative  thrombosis  is  practically  always  venous  in  origin,  the 
stopping-place  of  the  embolus  is  usually  in  the  lung.  If  the  emboli 
are  of  sufficient  size  or  number  to  block  the  more  important  branches 
of  the  pulmonary  arteries  or  the  artery  itself,  immediate  death  will  ensue. 

'  Lecene,  Archiv.  des  Maladies  du  Coeur,  March,  1909. 


I02  THROMBOPHLEBITIS — SUBDIAPHRAGMATIC    ABSCESS 

If  the  clot  is  broken  up  in  its  passage  through  the  right  heart,  so  that 
the  block  is  just  incomplete,  death  will  be  preceded  by  a  more  or  less 
prolonged  respiratory  struggle.  If  the  emboli  are  smaller,  strong  heart 
action  may  suffice  to  overcome  the  effect  and  the  patient  survive.  When 
minute  emboli  lodge  in  the  smaller  branches  of  the  pulmonary  arteries, 
infarction  of  the  lung  occurs. 

Embolism  occurs  in  from  20  to  30  per  cent,  of  all  cases  of  post- 
operative thrombosis.  It  comes  on,  as  a  rule,  any^vhere  from  four  to 
ten  days  after  the  operation,  but  it  may  be  postponed  until  two  or  more 
weeks.  The  fatality  is  variously  stated  at  about  50  per  cent.^  Le 
Normant^  found  that  embolism  occurred  after  ^  of  i  per  cent,  of  all 
celiotomies,  and  Ranzi,  in  y-Q  of  i  per  cent.  Frequently  it  has  been 
known  to  follow  some  slight  unusual  exertion  on  the  part  of  the  patient. 
This  may  be  as  small  a  thing  as  a  movement  to  accommodate  himself 
in  bed,  or  it  may  be  due  to  getting  out  of  bed  for  the  first  time,  sitting 
up  in  bed,  and  particularly  straining  during  defecation.  Death  may 
occur  within  a  few  minutes  from  the  first  symptoms  of  the  embolism, 
or  several  hours  may  elapse  before  the  fatal  termination.^  That  fatali- 
ties are  not  uncommon  are  shown  by  the  report  of  Fraenkel,*  which 
stated  that  during  1906  in  the  Vienna  General  Hospital  18  deaths 
occurred  from  postoperative  embolism  of  the  pulmonary  artery. 

It  is  said  to  be  more  likely  to  follow  operations  in  persons  who  are 
debilitated;  nevertheless,  it  is  known  to  happen  in  persons  who  are 
robust,  and  the  patient  may  be  apparently  perfectly  well  and  have  en- 
tirely recovered  from  the  operation.  Young  individuals  are  more  or 
less  exempt,  and  if  affected,  may  perhaps  recover,  presumably  on  ac- 
count of  the  yielding  elasticity  of  their  vessels,  which  may  allow  the 
blood  to  push  its  way  beside  a  clot.^ 

The  onset  is  always  sudden.  The  patient  finds  it  difficult  to  breathe, 
becomes  cyanotic,  and  cries  out  from  a  sense  of  suffocation.  His  face 
takes  on  an  anxious  look,  he  becomes  restless  and  complains  of  pain, 
he  gradually  becomes  pallid,  the  pulse  weakens  and  becomes  inter- 
mittent, and  the  respiration  gasping.  Unconsciousness  develops  and 
death  ensues. 

Recovery  depends  upon  the  size  and  the  situation  of  the  embolus. 

^  Mauclaire,  Archiv.  Gen.  de  Chir.,  June  25,  1908. 

^  Postoperative  Embolism  in  the  Lung,  Archiv.  Gen.  de  Chir.,  iqoq,  221. 

^  Ranzi,  Postoperative  Lung  CompHcations  of  the  Nature  of  Embolism,  Archiv  f. 
klin.  Chir.,  i9o8,lxxxvii,  350. 

*  Postoperative  Thrombosis-embolism,  Archiv  f.  klin.  Chir.,  tqoS,  lxxx\-i,  531. 

^  C.  L.  Gibson,  Pulmonary  Embolism  following  Operation,  Med.  Record,  190Q, 
Ixxv,  45. 


PULMONARY    EMBOLISM  lo 


O 


If  only  one  branch  of  the  artery  is  occluded,  a  strong  cardiac  action  may 
tide  over  the  individual.  If  the  embolus  is  so  situated  that  the  collateral 
circulation  through  the  pulmonary  capillaries  is  sufficient,  the  patient 
will  recover.  The  area  of  lung  tissue  vi^hich  is  cut  off  from  the  circula- 
tion becomes  an  infarct. 

Prophylaxis  is  a  matter  of  importance  in  this  condition.  It  is  a 
good  rule  never  to  operate  in  the  presence  of  varicose  veins  of  the  lower 
leg  without  first  ligating  or  removing  them.  Operations  should  not  be 
performed  where  phlebitis  or  anemia  is  known  to  exist.  If  the  pulse  is 
small  or  irregular,  digitalis  should  be  given  for  a  few  days  before  opera- 
tion. "  Varicose  veins  in  the  vicinity  of  abdominal  tumors,  such  as  are 
not  infrequently  seen  in  the  female  pelvis  in  connection  with  myomata 
of  the  uterus,  should  be  extirpated  with  the  growth  or  ligated  as  far  as 
possible  toward  the  pelvic  wall  to  avoid  the  likelihood  of  thrombosis."^ 
In  operating,  the  veins  should  be  handled  carefully,  and,  especially, 
injury  to  the  vessels  in  the  epigastrium  should  be  avoided  as  well  as 
friction  on  the  femoral  vein  and  manipulation  of  the  spermatic  cord. 
Patients  should  not  be  rushed  out  of  bed.  After  confinements,  opera- 
tions about  the  rectum  and  operations  on  the  uterus  and  adnexa,  par- 
ticularly w^here  the  possibility  of  sepsis  exists,  and  in  other  cases  where 
predisposition  might  exist,  the  patient  should  not  be  allowed  to  exert 
herself  in  any  way  for  a  week  or  more.  Her  position  in  bed  should  be 
changed  frequently,  and  light  respiratory  g3^mnastics  practised  in  bed. 

Treatment. — In  cases  of  large  embolus  and  sudden  and  com- 
plete blocking  of  one  of  the  main  branches  of  the  pulmonary  artery, 
death  may  occur  before  the  surgeon  has  time  to  arrive  upon  the  scene. 
If  the  patient  survives  the  first  shock  of  the  occlusion,  or  if  the  occlu- 
sion is  incomplete,  the  opportunity  for  treatment  should  not  be  neglected. 
Stimulation  should  be  supplied  by  means  of  hypodermic  injections  of 
quick-acting  and  freely  diffusible  agents,  such  as  camphor,  ether,  and 
ammonium  carbonate.     A  mixture  such  as  the  following, 

Camphor i ; 

Ether 3; 

Olive  oil 6, 

is  excellent  for  use  in  emergencies.  Oxygen  and  artificial  respiration 
are  indicated  where  the  patient' is  laboring  for  breath.  So  long  as  the 
heart's  action  is  strong,  hope  for  recovery  should  be  maintained. 

The  body  should  be  kept  warm  by  means  of  water-botUes  and  the 

^  Bartlett  and  Thompson,  Occluding  Pulmonary  Embolism,  Ann.  Surg.,  1908,  xhii, 

717. 


I04  THROMBOPHLEBITIS — SUBDIAPHRAGMATIC   ABSCESS 

room  should  be  kept  absolutely  quiet.  Complete  repose  should  be  en- 
joined. If  the  patient  is  restless,  morphin  should  be  administered  in 
small  doses  until  she  rests  comfortably.  If  she  lives  for  hours,  there  is 
a  possibility  of  collateral  circulation  about  the  block  asserting  itself, 
and  everything  should  be  done  to  assist  in  maintaining  the  circulatory 
equilibrium.  The  patient  should  be  allowed  plenty  of  fluids,  but  no 
milk,  calcium  salts,  or  carbonate  of  magnesia.^  If  the  patient  pro- 
gresses favorably,  the  area  of  lung  which  has  been  shut  off  from  the 
general  circulation  will  organize  and  become  a  hemorrhagic  infarct, 
w^hich,  after  a  few  days,  will  reveal  itself  to  physical  examination  of 
the  chest  as  an  area  of  consolidation.  The  infarct  in  itself  may  prove 
fatal,  or  secondary  pneumonia  develop  as  a  result. 

Operative  Treatment. — Recently,  under  the  leadership  of 
Trendelenburg,^  the  possibility  of  relieving  cases  of  pulmonary  embolism 
by  the  bold  procedure  of  cutting  down  upon  the  artery  and  removing  the 
embolus  has  been  urged,  and  the  operation  actually  performed  with 
sufficient  success  as  to  promise  some  advantage  in  suitable  cases.^ 

The  advisability  of  operative  interference  depends  upon  the  rapidity 
of  the  course  and  the  accuracy  of  the  diagnosis.  As  to  diagnosis,  the 
picture  is  characteristic.  Usually  there  is  a  sudden  collapse,  pallor, 
lividity  of  the  lips,  loss  of  pulse,  and  deep  and  distressed  respiration. 
In  addition  there  may  be  minor  indications,  such  as  a  previous  opera- 
tion in  which  the  larger  veins  were  exposed  or  ligated,  the  presence  of 
an  evident  thrombosis  of  the  femoral  or  other  veins,  fracture  of  one  of 
the  lower  extremities,  or  varicosities. 

As  to  rapidity,  death  does  not  always  result  as  suddenly  as  is  generally 
supposed.  Of  9  cases,  Trendelenburg  found  that  only  2  died  suddenly 
in  from  one  to  two  minutes.  In  the  other  7,  ten  minutes  to  one  hour 
elapsed  before  death  occurred. 

He  operates  by  making  a  transverse  incision  on  the  second  rib  and 
a  vertical  incision  on  the  left  side  of  the  sternum.  The  part  of  the 
second  rib  in  addition  to  the  sternum  is  resected  for  10  to  12  cm.  A  ver- 
tical incision  is  made  through  the  pleura  and  into  the  pericardium  at 
the  level  of  the  third  rib.  The  vessels  lie  a  little  underneath  the  sternum; 
they  are  pulled  forward  and  a  rubber  tube  is  passed  behind  the  aorta 
and  the  pulmonary  artery  and  afterward  drawn  upon.  Work  must 
then  be  proceeded  upon  with  the  utmost  celerity.  He  incises  the  pul- 
monary artery,  pulls  out  the-  embolus  with  a  pair  of  forceps,  and  im- 

^  Bidwell,  Pulmonary  Embolus  and  Thrombosis  after  Laparotomies,  Practitioner, 
Feb.,  1909.  2  Central,  f.  Chir.,  1908,  No.  35,  Beilage. 

^  See  Ann.  of  Surg.,  1908,  xlviii,  772. 


HEART-CLOT 


105 


mediately  closes  the  incision  in  the  arterial  ^Yall  with  clamps,  using  no 
more  than  forty-five  seconds.  He  then  releases  the  compress  and 
sutures  the  skin  at  leisure.  He  has  operated  three  times — the  first  man 
died  on  the  table;  the  second  recovered,  but  died  fifteen  hours  later 
from  heart  failure;  the  third  survived  the  operation  for  thirty-seven 
hours,  and  then  died  from  postoperative  hemorrhage  from  the  internal 
mammary  artery. 

Sievers,  following  the  Trendelenburg  technique,^  removed  an  embolus 
in  a  pulseless  patient,  who  survived  the  operation  fifteen  hours.  Tren- 
delenburg reported  a  case  in  a  man  of  forty-five  years,^  and  Murphy^ 
successfully  removed  an  embolus  from  the  common  iliac  artery.'* 

HEART-CLOT 

In  a  few  rare  cases  autopsy  has  shown  that  sudden  death  after 
operation  has  been  caused  by  the  lodgment  of  a  large  clot  in  the  heart 
itself.  It  is  said  that  if  the  clot  is  small,  it  may  cause  no  symptoms,  or 
nothing  more  than  transitory  murmurs  as  the  clot  encroaches  upon  one 
or  another  of  the  valves  of  the  heart.  In  some  cases  which  recovered 
the  diagnosis  was  made  on  the  presence  of  a  murmur,  feeble  and  tu- 
multuous action  of  the  heart,  and  attacks  of  dyspnea.  Such  a  symptom- 
complex  may  be  followed  in  a  few  days  by  evidences  of  pulmonary 
embolism,  which  can  be  interpreted  to  mean  that  the  clot,  freeing  itself 
from  the  heart,  has  been  carried  into  the  pulmonary  artery,  where  it 
has  lodged  as  an  embolus,  or  that  there  has  been  an  extension  of  clot 
formation  into  the  pulmonary  artery  and  subsequent  embolism. 

In  cases  which  end  fatally  differentiation  between  heart-clot  and 
pulmonary  embolism  cannot  be  made  certain  without  autopsy.     In 

^  Fall  von  Embolic  der  Lungenarterie  nach  der  Method  von  Trendelenburg  operiert, 
Deut.  Zeit.  f.  Chir.,  1908,  93. 

^  Operationen  der  Embolie  der  Lungenarterie,  Deut.  med.  Woch.,  1908,  xxxiv,  1172. 

^  Jour.  Amer.  Med.  Assoc,  1909,  52,  1661. 

*  Busch  (Ueber  plotzliche  Todesfalle  mit  besonderer  Beriicksichtigung  der  Indikations- 
stellung  fiir  die  Trendelenbergsche  Operation  bei  Lungenembolie,  Deut.  med.  Woch., 
vol.  XXXV,  July  22,  1909)  states  that  of  878  fatalities  in  9727  patients  in  Korte's  surgical 
service  in  Berlin  during  the  last  four  years,  22  of  the  deaths  occurred  suddenly,  and 
the  symptoms  indicated  pulmonary  embolism.  Of  these  22  cases  in  12  death  was 
instantaneous.  Autopsy  in  7  showed  embolism  in  4.  One  showed  a  thrombus  which 
could  readily  have  been  removed  by  the  Trendelenburg  operation.  In  10  cases  the  symp- 
toms persisted  ten  minutes  to  three  hours  before  death.  Autopsy  revealed  embolism 
in  6,  and  conditions  would  have  been  favorable  for  operative  intervention  in  5.  In  4  other 
cases  the  assumed  embolism  did  not  exist,  death  having  been  due  to  fatty  degeneration  of 
the  heart.  Korte  advocates,  if  the  symptoms  of  embolism  present  themselves,  morphin 
to  tranquilize  the  respiration,  digitalis  injected  into  the  vein  (better  strophanthin).  Mean- 
while preparation  should  be  made  for  the  Trendelenburg  operation,  which  should  be 
resorted  to  if  other  measures  do  not  work. 


Io6  THROMBOPHLEBITIS — SUBDIAPHRAGMATIC   ABSCESS 

the  following  case,  which  was  diagnosed  clinically  as  heart-clot,  we 
regret  that  autopsy  was  not  permitted. 

Male,  forty-eight  years  old.  Operation  two  years  before  for  acute  ap- 
pendicitis; right  rectus  incision,  splitting  fibers.  Third  day  a  subsequent 
sepsis  in  wound;  a  complete  disorganization  of  the  ligatures  and  sutures,  and 
gradual  development  of  ventral  hernia  at  site  of  operation.  Present  operation 
for  repair  of  hernia.  Sac  excised;  found  to  contain  most  of  omentum,  trans- 
verse colon,  and  many  coils  of  small  gut.  Omentum  tied  off  in  mass  with 
interlocked  sutures  and  intestines  freed  with  much  difficulty  from  sac.  Adhe- 
sions hgated,  peritoneum  closed,  and  fibers  of  rectus  muscle  brought  together 
with  mattress  sutures.  Rectus  sheath  closed  in  the  same  way.  Good  ether 
recovery,  there  being  almost  no  vomiting.  Subsequent  convalescence  up  to 
the  tenth  day  uneventful;  normal  temperature  and  pulse  throughout;  gas 
pains  singularly  absent,  there  being  no  necessity  for  enemas  more  than  once  or 
twice.  On  the  tenth  day  climax  of  good  subjective  feeling;  temperature  and 
pulse  normal,  appetite  good,  and  patient  looking  forward  to  sitting  up;  sub- 
cutaneous stitch  had  been  removed  two  days  previously.  On  the  afternoon  of 
the  tenth  day  patient  was  awakened  out  of  his  sleep  by  intense  precordial  pain. 
The  pulse  could  at  that  time  be  felt,  but  was  weak,  occasionally  fluttering, 
with  the  rate  at  about  loo;  respirations  were  40;  patient  was  gray,  as  with  the 
fear  of  death,  but  there  was  no  cyanosis.  A  hot-water  bag  was  put  over  the 
heart  and  hypodermic  stimulants  of  various  kinds  given.  He  failed  to  rally, 
the  distress  remaining  constant  about  the  heart.  There  was  no  dilatation  of 
that  organ  apparent ;  no  cyanosis  appeared  even  to  the  end.  He  died  in  about 
forty  minutes  from  the  first  onset  of  symptoms. 

PYLEPHLEBITIS 

Ascending  septic  infection  of  the  portal  veins  after  appendicitis  is 
by  no  means  rare.  Gerster^  reports  that  it  was  found  nine  times  in 
1 187  cases  of  appendicitis  operated  upon  at  the  Mt.  Sinai  Hospital. 
Munro^  reported  a  series  of  9  cases. 

The  condition  appears  to  originate  in  the  thrombosis  which  naturally 
occurs  in  the  appendicular  veins  after  their  obliteration.  There  is  direct 
line  of  communication  open  between  these  veins  and  the  portal  system 
through  the  superior  mesenteric  vein.  The  case  need  not  be  clinically 
a  septic  one,  for  the  complication  occurs  after  clean  interval  operations 
as  well  as  operations  performed  during  the  acute  stage  and  those  com- 
plicated by  abscess  formation. 

The  pathology  has  been  studied  by  Thompson^  in  a  series  of  8  cases. 

^  New  York  Med.  Record,  1903,  June  27. 
^  Boston  Med.  and  Surg.  Jour.,  1902,  81. 
^Boston  City  Hospital  Med.  and  Surg.  Reports,  13th  series. 


SUBDIAPHRAGMATIC   ABSCESS  I07 

Septic,  partly  disintegrated  thrombi  are  found  at  autopsy  to  extend 
from  the  veins  draining  the  appendix  region  to  the  portal  vein,  and 
this  is  either  filled  with  pus  or  occluded  by  thrombus.  Small  bits  of 
septic  clot,  becoming  dislodged  from  the  mass  in  the  portal  vein,  are 
carried  up  into  the  liver  until  they  are  arrested  in  the  finer  branches, 
and  there  they  are  found  to  set  up  multiple  abscesses  in  the  liver  sub- 
stance, usually  by  preference  on  the  anterior  superior  surface  of  the 
right  lobe. 

The  condition  is  not  always  readily  or  correctly  diagnosticated,  partly 
because  of  its  rapid  course.  It  is  most  likely  to  be  confused  with  a 
secondary  peritonitis.  It  should  always  suggest  itself  whenever  a 
patient,  shortly  after  an  appendectomy,  develops  chills  and  an  irregular 
high  temperature.  Other  signs  to  be  looked  for  are  tenderness  along 
the  outer  border  of  the  right  rectus  muscle,  enlargement  of  the  spleen 
and  liver,  with,  in  some  cases,  jaundice  and  rapid  and  profound  prostra- 
tion. 

The  prognosis  is  poor  because  of  the  frequency  of  the  occurrence  of 
liver  abscesses.  A  single  abscess  may  be  drained  and  the  patient  recover, 
but  in  the  face  of  multiple  abscesses,  which  is  the  rule,  operation  offers 
little  hope  for  relief.  Nevertheless,  exploratory  operation  should  always 
be  performed  and  abscesses  evacuated  and  drained. 

SUBDIAPHRAGMATIC  ABSCESS 

Subdiaphragmatic  abscess  may  occur  after  operations,  particularly 
about  the  stomach  and  appendix.^  After  stomach  operations  it  may 
represent  a  local  peritonitis  following  a  leak  in  a  posterior  gastro- 
enterostomy; it  may  be  the  result  of  the  extension  of  infection  along  the 
subperitoneal  lymphatics  from  the  appendix  or  of  abscess  of  the  liver 
following  pylephlebitis.  Any  suppurative  inflammation  originating  in 
or  about  any  viscus  in  the  upper  half  of  the  abdomen  will  tend  to  gravi- 
tate free  pus,  provided  the  patient  is  flat  on  his  back,  to  the  capacious 
hollows  under  and  about  the  liver.  It  may  result  accordingly  from 
suppurative  cholecystitis,  perinephritis,  perforation  of  the  diaphragm 
in  empyema,  or  it  may  represent  the  last  focus  of  a  general  peritonitis. 

Generally  speaking,  abscesses  following  appendicitis  and  liver  ab- 
scess occur  on  the  right  side  of  the  suspensory  ligament  of  the  liver,  those 
originating  in  the  stomach,  on  the  left.  Pleurisy  with  effusion,  either 
serous  or  purulent,  occurs  as  a  complication  in  over  half  of  the  cases. 

1  See  A.  Lawrence  Mason,  Subphrenic  Abscess,  Boston  Med.  and  Surg.  Jour.,  1893, 
cxxix,  p.  217,  for  history.  See  alsc^  Catz  and  Kendirdjy,  Les  Abces  Sous-phrenicjues, 
Rev.  de  Gynec.  et  de  Chir.  Abdom.,  1908,  xii,  469. 


Io8  THROMBOPHLEBITIS — SUBDIAPHRAGMATIC    ABSCESS 

Gas  in  varying  quantity,  the  result  of  bacterial  decomposition,  is  present 
in  about  half  of  the  cases;  indeed,  the  cavity  may  contain  but  little  else. 
When  gas  and  pus  are  both  present  in  sufficient  quantity,  shifting  dul- 
ness  may  be  demonstrated  as  the  patient  turns. 

The  symptoms  are  usually  slow  in  developing,  and  are  apt  to  be 
readily  confused  with  those  of  pleurisy  with  effusion  and  empyema. 
The  temperature  is  irregularly  elevated,  and  there  is  often  cough  and 
shallow  respiration.  There  is  localized  pain  and  tenderness  and  there 
may  be  chills.  As  the  collection  of  pus  increases  the  symptoms  become 
aggravated.  The  lower  edge  of  the  liver  is  pushed  down  perceptibly 
and  the  intercostal  spaces  are  likely  to  bulge.  Some  cases  show  local 
edema.  The  difficulty  in  diagnosis,  where  the  history  of  the  case  does 
not  give  any  assistance,  is  compHcated  by  the  presence  of  the  pleural 
effusion,  which  nearly  always  accompanies  a  subdiaphragmatic  abscess. 
The  aspirating  needle  is  always  of  service  in  locating  the  pus-cavity;  to 
reach  the  perihepatic  space  the  needle  must  pierce  the  chest-wall  and 
then  pierce  the  diaphragm.  If  the  diaphragm  is  not  paralyzed  by  the 
inflammation  or  pressure,  the  needle  which  has  pierced  it  will  move  up 
and  down  with  respiration.  Pus  from  below  the  diaphragm  flows  on 
inspiration;  pus  above  the  diaphragm  is  expelled  by  expiration.  If 
nothing  but  air  or  gas  escapes,  the  probability  is  that  it  issues  from  below 
the  diaphragm. 

The  prognosis  is  serious.  With  operation  it  is  far  better  than 
without,  although  in  rare  cases  the  abscess  resolves,  or  it  discharges 
externally,  into  a  bronchus,  or  through  one  of  the  hollow  \ascera.  Un- 
operated  cases  sometimes  drag  on  for  weeks  and  months.  The  mor- 
tality of  subdiaphragmatic  abscess  from  all  causes  is  generally  stated 
at  about  50  per  cent.  Two-thirds  of  the  cases  that  recover  get  well 
with  operation  and  one-third  without. 

The  treatment  consists  in  incision  and  drainage;  aspiration  is  to 
be  considered  as  a  diagnostic  method  only.  It  is  often  wise  to  have  the 
operation  follow  immediately  upon  the  aspiration  if  this  be  positive. 
If  there  is  bulging  at  any  point,  the  incision  is  made  over  this  area,  other- 
wise it  is  preferable  to  go  in  through  the  bottom  of  the  pleural  cavity  or 
just  below  the  reflexion  of  the  parietal  pleura.  About  two  inches  of  the 
ninth  and  tenth  ribs  are  resected  in  the  posterior  axillar}-  line.  The 
pleura  may  be  pushed  up  and  the  diaphragm  incised  below  it,  or  the 
pleural  cavity  may  be  incised  and  the  surfaces  of  the  pleura  sewn  together 
above.  If  need  be,  an  empyema  and  a  subdiaphragmatic  abscess  may 
be  drained  through  the  same  wound.  Drainage  should  be  ample  and 
rubber  tubino;  is  usuallv  more  efficient  than  crauze. 


CHAPTER  X 

ARTIFIQAL  RESPIRATION;  OXYGEN;  ELECTRICITY 

Artificial  respiration  has  its  chief  place  in  surgery  in  relation  to 
anesthesia.  It  must  be  resorted  to  whenever  respiration  fails  while 
the  patient  is  under  the  influence  of  the  anesthetic,  and  again  whenever 
asphyxia  threatens  a  patient  recovering  from  anesthesia.  In  the  former 
case  the  patient  has  to  be  dealt  with  on  the  table.  If  the  anesthetic  is 
ether,  removing  the  cone  and  exciting  rhythmic  pressure  on  the  sternum 
two  or  three  times  will  usually  suffice  to  start  up  respiration.  If  chloro- 
form is  being  used,  the  outlook  is  more  serious,  as  with  this  agent,  in 
contradistinction  to  ether,  the  cardiac  action  may  cease  simultaneously 
with,  or  closely  following,  the  cessation  of  respiration.  In  either  case, 
where  the  respiratory  failure  is  due  to  direct  action  of  the  agent,  and 
not  to  mechanical  causes,  the  value  of  artificial  respiration  will  depend 
upon  whether  the  heart  has  been  so  far  weakened  as  to  be  unable  to 
carry  on  the  circulation.  Practically,  then,  if  the  heart  is  beating 
rhythmically,  and  a  pulse  can  be  felt,  if  the  anesthetic  is  removed  and 
artificial  respiration  be  immediately  instituted,  it  should  invariably  be 
successful.  If,  however,  a  highly  concentrated  vapor  has  been  inhaled 
and  the  heart  has  been  weakened  thereby,  and  has  ceased  to  beat  or  is 
feebly  fluttering,  the  prognosis  is  not  good. 

In  recovery  from  the  anesthetic  the  proposition  is  somewhat  different. 
Here  the  failure  in  respiration  arises  from  some  mechanical  interference. 
Fatal  accidents  have  resulted  from  such  foreign  objects  as  plates  of 
false  teeth,  plugs  of  gum,  or  tobacco  falling  into  the  air-passages.  The 
common  causes  of  postanesthetic  asphyxia  are  the  aspiration  into  the 
larynx  of  vomited  matter  or  accumulated  blood  or  saliva  in  the  mouth 
and  the  closing  off  of  the  larynx  by  the  tongue,  in  a  state  of  relaxation, 
falling  back  into  the  throat.  The  treatment  of  this  form  resembles 
that  for  asphyxia  by  drowning. 

We  shall  consider  two  forms  of  artificial  respiration:  the  supine  and 
the  prone.  The  supine  is  ordinarily  better  when  asphyxia  occurs  on 
the  operating  table;  the  prone  is -of  advantage  in  cases  where  asphyxia 
is  due  to  obstruction. 

The  supine  method — named  for  Sylvester — attempts  to  imitate 
natural  inspiration  by  increasing  the  capacity  of  the  chest.     This  is 

109 


no 


ARTIFICIAL    respiration;    OXYGEN;    ELECTRICITY 


efifected  by  drawing  the  arms  upward  toward  the  head  (Fig.  37).  Ex- 
piration occurs  as  the  arms  are  gradually  lowered  (Fig.  38)  again  to 
the  sides,  and  is  completed  by  exerting  pressure  on  the  thorax  (Fig.  39). 


Fig.  36. — Artificial  Respiration  on  the  Table. 

One  man  at  head  holds  jaw  forward  and  exerts  rhythmic  traction  on  tongue;  one  man  at  each  side  manipulates 

an  arm. 

This  maneuver  requires  three  persons — one  standing  on  either    side 
to  manipulate  an  arm  and  one  forcibly  to  hold  forv\^ard  the  tongue  by 


Fig.  37. — Artifk  lAL  Respiration.     Supine  Method. 
Arms  extended.     Inspiration. 


means  of  a  tongue  forceps  and  to  swab  out  the  mouth  if  necessary. 
The  two  operators  should  work  slowly  and  in  unison  and  the  rhythm 
should  be  that  of  normal  respiration. 


ARTIFICIAL    RESPIRATION 


III 


In  cases  of  emergency  arising  after  the  anesthetic,  especially  where 
the  attendant  is  alone  and  cannot  get  help,  there  are  many  advantages 
in  the  "  prone  pressure  method "  recently  described  by  Schaefer.^  In 
this  method  the  patient   is   laid  belly  down  upon  the    floor,  face  to 


Fig.  38. — Artificial  Respiration.    Supine  Method. 
Beginning  expiration. 


one  side,  and  arms  at  right  angles  to  the  body.  The  operator  kneels 
at  his  side  and  places  his  hands  over  the  lowest  ribs  of  the  patient,  one 
on  either  side.     Then,   swinging  slowly  forward  and  backward,   by 


r-.-5.fi||f 

Fig.  39. — Artificial  Respiration.    Supine  Method. 
Completed  expiration.     Arms  flexed,  compression  of  chest  by  pressure  on  elbows. 

allowing  his  weight  to  fall  rhythmically  on  and  off  his  wrists,  he  can 
compress  not  only  the  thorax,  but  also  the  abdomen  against  the  ground, 
thus  forcing  the  air  from  the  lungs.     As  the  pressure  is  relaxed  the 

^  Jour.  Amer.  Med.  Assoc,  190S,  li,  Soi. 


112  ARTIFICIAL   RESPIRATION;    OXYGEN;    ELECTRICITY 

elasticity  of  the  parts  causes  them  to  resume  their  natural  shape  and  air 
is  drawn  in  through  the  glottis.  The  pressure  is  exerted  gradually  and 
slowly  over  a  space  of  some  three  seconds.  It  is  then  removed  for  two 
seconds  and  again  applied,  and  so  on,  at  the  rate  of  about  twelve  times 
per  minute.  This  method  does  not  tire  the  operator;  it  requires  only 
one  man;  the  tongue  falls  naturally  forward  and  does  not  need  to  be 
held;    mucus,  vomitus,  or  blood  drain  readily  from  the  mouth.^ 

Rough  artificial  respiration  may  be  the  finishing  touch.  The  first 
move  should  always  be  expiratory,  not  inspiratory.  Rapid  and  violent 
efforts  may  lead  to  dilatation  of  the  heart. 

Laborde-  introduced  the  method  of  reflex  stimulation  of  respiration 
by  means  of  rhythmic  traction  on  the  tongue.  The  tip  of  the  tongue  is 
seized  in  tongue-forceps,  and  it  is  pulled  out  its  entire  length  rhythmically, 
at  the  rate  of  about  eighteen  times  a  minute.  Sufficient  force  should 
be  exerted  to  lift  the  glottis  clear  away  from  the  trachea;  the  novice  will 
be  surprised  at  the  extent  of  the  tongue  which  appears  when  the  pro- 
cedure is  properly  performed.  This  method  should  always  be  carried  on 
with  the  supine  form  of  artificial  respiration  when  some  one  may  be 
spared  to  perform  it.  The  extension  of  the  tongue  should  be  synchron- 
ous with  inspiration;  othenvise,  before  artificial  respiration  is  com- 
menced, a  free  airway  should  be  insured  by  some  means  of  holding  for- 
ward the  tongue,  such  as  tying  a  silk  thread  through  its  tip  and  about 
the  subject's  ear. 

A  recent  method  of  resuscitation  consists  in  passing  a  stream  of 
oxygen  through  a  laryngotomy  or  O'Dwyer  intralaryngeal  tube.^ 

The  use  of  electricity  has  been  widely  advocated.  The  faradic  cur- 
rent acts  beneficially  by  stimulating  respiration.  The  current  should 
not  be  strong,  as  cardiac  action  may  be  inhibited.  The  diaphragm  may 
be  excited  to  contraction  by  stimulation  of  the  phrenic  nerve.  One 
pole  should  be  placed  over  the  pit  of  the  stomach,  the  other  at  the  angle 
of  the  jaw,  near  the  anterior  border  of  the  sternomastoid.* 

^  See  also  A.  Keith,  Mechanism  Underhdng  the  Various  Methods  of  Artificial  Respira- 
tion, Lancet,  1909,  i. 

^  Les  Tractions  Rhythmees  de  la  Langue,  Paris,  1S95. 

^  See  F.  Kuhn,  Resuscitation  in  Apparent  Death  by  Means  of  Oxygen  and  Intubation, 
Therap.  Monats.,  Nov.,  1908,  xxii. 

^  See  E.  A.  Spitzka,  Resuscitation  of  Persons  Shocked  by  Electricity,  Jour.  Med. 
Soc.  of  New  Jersey,  1909,  v,  549.  Crile  (Surgical  Anemia  and  Resuscitation, 
Am.  Jour.  Med.  Sciences,  1909.,  cxxxvii,  469)  describes  the  following  technique 
for  resuscitation  after  the  heart  stops  beating  from  chloroform:  The  patient  in 
the  supine  posture  is  subjected  at  once  to  rhythmic  pressure  on  the  chest  with 
one  hand  on  each  side  of  the  sternum.  This  pressure  produces  artificial  respiration 
and  a   moderate  arterial   circulation.     A  cannula  is  inserted  toward  the  heart  into  an 


RESUSCITATION  II3 

artery.  Normal  saline,  Ringer's  or  Locke's  solution,  or,  in  their  absence,  sterile  water, 
is  infused  by  means  of  a  funnel  and  rubber  tubing.  As  soon  as  the  flow  has  been  begun,  the 
rubber  tubing  near  the  cannula  is  pierced  with  a  needle  of  a  hypodermic  syringe  loaded 
with  i:  1000  adrenalin  chlorid,  and  from  15  to  30  min.  is  at  once  injected.  The  injection 
is  rapid,  in  a  minute  if  needed.  Synchronously  with  the  injection  of  the  adrenalin,  the 
rhythmic  pressure  on  the  thorax  is  brought  to  a  maximum.  The  resulting  arterial  circula-. 
tion  distributes  the  adrenalin  and  spreads  its  stimulating  contact  with  the  artery,  bringing 
a  wave  of  powerful  contractions  and  producing  a  rising  arterial  pressure.  When  the  cor- 
onary pressure  rises  to  40  mm.,  the  heart  is  likely  to  spring  into  action.  As  soon  as  the 
heart-beat  is  established,  the  cannula  should  be  withdrawn.  Bandaging  the  extremities 
and  abdomen  tightly  over  large  masses  of  cotton  is  very  useful. 

Ringer's  solution  has  the  following  composition  (Jour,  of  Phys.,  Lond.,  1885,  vi,  361): 

I^.     NaCl 0.07  per  cent. 

KCl 0.03  per  cent. 

CaClj 0.026  per  cent,  (crystals). 

Locke's  solution  is  made  up  as  follows  (Jour,  of  Phys.,  Lond.,  1895,  xviii,  332): 

]^.     CaCl2 0.024  per  cent,  (crystals) 

KCl 0.042  per  cent. 

NaHCOj 0.03  per  cent. 

NaCl 0.9  per  cent. 

Dextrose o.  i  per  cent. 

8 


CHAPTER  XI 

DIET  AFTER  OPERATION 

Ether,  rather  more  than  chloroform,  is  apt  to  occasion  nausea  and 
vomiting  during  the  period  in  which  the  patient  is  recovering  conscious- 
ness and  after.  The  degree  to  which  this  occurs  seems  to  depend  on  the 
duration  of  anesthesia,  the  amount  of  anesthetic  given,  the  evenness 
of  its  administration,  the  length  of  time  consumed  in  going  under,  and 
the  amount  of  food  in  the  patient's  stomach.  The  vomiting  may, 
however,  be  considerable  in  cases  where  no  reason  can  be  assigned  and 
in  susceptible  persons.  Usually  there  will  be  no  desire  and  no  necessity 
for  food  until  the  effects  of  the  anesthetic  have  passed  off,  and  then  if 
a  tendency  to  nausea  persists,  the  diet  should  be  a  fluid  one,  consisting 
of  an  ounce  or  two  of  mxilk,  buttermilk,  beef-tea,  cocoa,  tea,  or  coffee, 
according  to  the  patient's  desire,  and  so  long  as  the  gastric  irritation 
remains. 

If  the  operation  has  been  a  severe  one,  or  if  the  patient  is  suffering 
from  hemorrhage  or  shock,  it  may  be  of  importance  for  him  to  receive 
fluid  or  nourishment  immediately,  and  in  this  case  it  may  be  given  by 
rectum  or  subcutaneously,  even  before  he  has  fully  recovered  from  the 
anesthetic. 

In  abdominal  sections  it  may  be  wise  to  give  the  gastro-intestinal 
tract  complete  rest  by  abstaining  from  all  food  by  mouth  for  twenty- 
four  hours,  and  in  operations  on  the  stomach  the  patient  may  be  sus- 
tained by  rectal  enemata  for  t^vo  or  three  days.  The  danger  in  these 
cases  from  the  occurrence  of  vomiting,  or  of  stasis  fermentation  and 
flatulence,  is  far  greater  than  that  of  inanition  from  abstinence  from  food. 
In  general  it  may  be  laid  down  as  a  good  rule  that  if  there  is  any  opera- 
tive lesion  of  any  portion  of  the  alimentary  tract,  that  portion  should 
be  given  as  complete  rest  as  possible  for  a  reasonable  length  of  time. 
After  mouth-feeding  has  been  started  articles  of  diet  should  be  selected 
which  do  not  call  for  digestive  action  by  the  particular  portion  of  the 
gastro-intestinal  canal  which  has  been  involved  in  the  operation. 

In  selecting  the  diet  stress  should  be  laid  upon  one  other  point, 
namely,  not  to  include  any  food-stuff  which  in  the  process  of  digestion 
is  likely  to  give  rise  to  fermentation  or  formation  of  gas  and  so  cause 
flatulence  and  distention.     Certain  staple  articles  of  food,  such  as  milk,, 

114 


DIET    AFTER    OPERATION  II5 

are  extremely  likely,  under  the  conditions  of  intestinal  stasis  which 
exist  after  a  celiotomy,  to  be  improperly  digested  and  give  rise  to  fer- 
mentation. Thus  milk,  even  when  peptonized,  is  not  to  be  considered 
a  proper  food  for  mouth-feeding  after  abdominal  operations.  It  is 
not  digested  by  the  stomach,  and  as  curd  it  may  pass  a  long  way  down 
the  intestines  and  cause  flatulence.  Peptonized  milk  has  not  these 
drawbacks,  but  patients  rarely  like  it;  flavored  with  cocoa  it  may  be 
relished.  Sir  A.  E.  Wright^  observes  that  the  time-honored  milk  diet 
in  acute  diseases  and  after  operation  is  a  direct  stimulation  to  the  onset 
of  thrombosis,  owing  to  the  large  amount  of  calcium  present  in  such  a 
diet  increasing  the  coagulability  of  the  blood. 

An  excellent  substitute  for  milk — unirritating,  easily  digested 
without  gas  formation — is  albumin-water,  made  by  beating  up  the 
whites  of  three  eggs  in  a  pint  of  water.  It  may  be  flavored  with  lemon 
and  sugar,  and  2  pints  may  be  taken  to  represent  a  fair  amount  of 
nourishment  for  twenty-four  hours. 

Another  form  of  fluid  nourishment  which  can  often  be  made  use 
of  to  great  advantage  is  the  homely  drink,  "raisin  tea."  This  is  made 
by  pouring  a  glass  of  boiling  water  upon  a  half  cup  of  chopped  raisins, 
stewing  gently  for  an  hour,  and  straining.  The  filtrate  may  be  given 
full  strength  or  diluted  with  water  or  albumin-water,  hot  or  cold,  as 
the  patient  desires.  It  is  highly  nutritious,  representing  a  high  pro- 
portion of  grape-sugar,  the  most  readily  assimilable  form  of  carbo- 
hydrate.    To  the  patient  it  is  palatable  and  refreshing. 

Beef-tea,  so  often  added  to  the  invalid's  diet,  must  be  considered 
only  as  a  stimulant.  Beef-juice,  extracted  from  fresh,  juicy  beef-steak 
by  means  of  a  meat-press  or  lemon-squeezer,  is  nutritious,  although  it 
contains  hardly  more  albumin  than  milk.  It  may  be  served,  slightly 
warmed,  with  a  pinch  of  salt.  The  proprietary  beef-extracts  are  hardly 
worth  considering. 

Recently,  in  part  as  the  result  of  the  investigations  of  Metchnikoff, 
buttermilk  has  come  into  some  favor  in  the  postoperative  dietary. 
This  is  a  wholesome,  cooling,  and  diuretic  drink,  and  is  often  fancied 
by  patients  to  whom  whole  milk  is  obnoxious.  Its  food  value  is  about 
that  of  skimmed  milk,  and  it  consists,  besides  water,  chiefly  of  albumin, 
finely  coagulated  casein,  and  sugar,  which  has  been  converted  largely 
into  lactic  acid.  It  is,  as  a  rule,- readily  digested,  even  in  cases  where 
the  proteids  and  fats  are  not  well  borne,  and  there  is  said  to  be  less  gas 
formation  and  residue  than  with  milk.  It  should  be  drunk  fresh  and 
cold,  perhaps  diluted  with  siphon  soda.      Buttermilk  made  by  inocu- 

^  Folia  Therapeutica,  Jan.,  1909. 


Il6  DIET    AFTER    OPERATION 

lating  milk  with  strains  of  bacteria  represented  in  the  various  forms 
of  tablets  now  on  the  market  has  no  advantage  in  this  connection  over 
fresh  buttermilk  obtained  from  a  clean  dairy/ 

The  stimulation  value  of  sipping  should  be  remembered.  Sir 
Lauder  Brunton^  says: 

"More  people  in  this  country  shorten  their  lives  by  overeating  than  by 
starvation,  and  an  unnecessary  excess  of  animal  food  not  only  leads  to 
physical  disorders,  but  to  an  irritable  and  irascible  frame  of  mind.  In- 
stead of  trying  to  remove  the  depression  between  eleven  and  four  by 
taking  a  glass  of  wine  or  spirits,  a  much  better  plan  is  to  sip  a  glass  of 
water  or  soda-water  and  eat  a  biscuit.  If  a  greater  stimulus  than  this  is 
needed,  a  glass  of  hot  eau  sucree  with  a  lemon  squeezed  into  it  may  be 
taken.  It  is  not  a  matter  of  indifference  whether  the  water  be  drunk 
down  at  a  draught  or  sipped,  for  the  act  of  sipping  has  a  very  extra- 
ordinary effect  upon  the  circulation,  as  my  friend,  Professor  Kronecker, 
has  shown;  during  the  act  of  swallowing  the  power  of  the  restraining  nerves 
upon  the  heart  seems  to  disappear,  and  if  any  one  will  coimt  their  pulse 
before  they  take  a  sip  of  water  and  while  they  are  taking  it,  they  will  find 
that  while  they  are  swallowing  the  pulse  becomes  nearly  twice  as  quick 
as  before.  It  has  long  been  known  that  while  sucking  ale  through  a  straw 
a  person  becomes  drunk  much  more  quickly  than  when  the  same  quantity 
is  taken  at  a  single  draught,  and  it  is  probable  that  this  alteration  in 
the  circulation  by  the  process  of  suction  has  had  much  to  do  with  this 
curious  result." 

^  "It  is  difficult  to  understand  why  putrefactive  bacteria  should  not  be  present  in  the 
milk  when  tablets  are  used,  but  should  be  present  in  the  same  milk  when  the  tablets  are  not 
used.  If  the  purest  milk  obtainable  is  used,  the  putrefactive  bacteria  which  are  always 
present  in  the  milk — even  of  the  best  grade — ^will  not  develop  because  the  normal  lactic 
acid  bacteria  antagonize  them.  It  is  clear  that  if  the  same  dairyman  who,  by  observing 
cleanliness  in  his  establishment,  furnishes  a  good  quality  of  sweet  milk,  will  observe  the 
same  care  in  handling  cream  for  making  butter,  his  buttermilk  also  will  be  wholesome 
and  clean.  More  criticism  of  a  similar  nature  could  be  made  in  regard  to  the  use  of  com- 
mercial preparations  for  fermenting  milk.  Where  clean,  certified  milk  can  be  obtained, 
the  use  of  these  various  preparations  seems  unnecessary.  Inasmuch  as  it  is  not  always 
feasible  to  obtain  certified  raw  milk,  however,  boiled  or  pasteurized  milk  is  to  be  preferred. 
It  is  here  that  the  artificial  'starter'  is  of  value.  After  the  first  inoculation,  the  same 
product  can  be  obtained  by  inoculating  pasteurized  or  boiled  milk  wdth  a  small  amount 
of  the  first  lot  inoculated,  with  proper  precautions  of  cleanliness.  Once  started,  this 
process  may  be  continued  for  a  long  time  without  having  to  renew  the  '  starter.'  Those 
who  have  confidence  in  the  merits  of  the  Bulgarian  bacillus  of  Metchnikoff  can  procure  one 
of  the  preparations  containing  this  bacillus  and  then  proceed  in  the  same  manner  as  mth 
the  butter  starter."  (Jour.  Amer.  Med.  Assoc,  editorial  article,  Jan.  30,  1909,  lii,  397, 
quoting  the  results  of  Heinemann;  Lactic  Acid  as  an  Agent  to  Reduce  Intestinal  Fer- 
mentation, Jour.  Amer.  Med.  Assoc,  1909,  lii,  372  ). 

^  On  Disorders  of  Assimilation,  Digestion,  etc.,  London,  1901,  108. 


DIET    AFTER    OPERATION  II7 

The  healing  of  all  surgical  injuries  is  promoted  by  an  abundant 
nourishing  diet.  When  it  can  be  taken,  therefore,  such  a  one  of  ready 
digestibility  should  be  selected.  Care  should  be  taken,  however,  with 
a  patient  in  bed  to  supervise  the  evacuations,  or  otherwise  the  channels 
for  the  removal  of  waste  may  be  clogged  and  the  object  in  view  defeated. 
With  this  caution  in  mind  there  is  no  harm,  as  a  rule,  in  allowing  a 
patient  suffering  from  some  minor  surgical  disorder,  or  kept  in  bed 
during  the  healing  of  a  wound  or  fracture,  or  after  a  slight  operation,  in 
the  absence  of  fever  or  sepsis,  to  satisfy  his  appetite  on  the  animal  and 
vegetable  diet  to  which  he  is  accustomed.  If,  in  a  prolonged  con- 
valescence, the  appetite  flags,  it  will  be  of  advantage  to  vary  the  diet, 
or  it  may  become  necessary  to  prescribe  beer,  sherry,  or  brandy  and 
soda,  to  be  taken  with  meals. 

If,  on  the  other  hand,  the  patient  has  been  severely  injured,  or  has 
passed  through  a  considerable  operation  and  is  suffering  from  shock  or 
loss  of  blood,  or  is  in  pain,  food  is  less  desirable  than  rest  and  stimula- 
tion. In  such  a  case  overfeeding  is  attended  by  positive  harm.  Coffee, 
milk,  and  broths  may  be  offered,  but  it  is  unwise  to  urge  food  upon 
the  patient  where  there  is  nausea  or  indifference.  It  is  better  to  utilize 
the  rectum,  when  necessary,  for  feeding  and  even  for  medication,  until 
the  stomach  recovers  its  tone. 

In  surgical  inflammatory  conditions,  such  as  sepsis,  the  patient's 
strength  should  be  supported,  as  in  any  fever,  by  a  sufficient  amount 
of  readily  assimilable  food.  In  severe  cases  the  patient  should  be  made 
to  take  milk,  or  milk  with  one-half  the  quantity  of  hot  water,  or  milk 
diluted  by  one-third  with  siphon  soda,  in  quantities  of  4  to  6  ounces. 
At  an  occasional  feeding  beef-juice  or  strong  chicken  or  mutton  broth 
may  be  substituted.  If  the  pulse  becomes  feeble,  stimulants,  such  as 
whisky  or  brandy,  should  be  given.  If  the  patient  has  any  appetite, 
semisolids,  such  as  gruels,  custard,  beef  jelly,  or  a  raw  egg  beaten  in 
sherry,  are  to  be  recommended.  As  improvement  occurs,  rice,  cream- 
toast,  scrambled  egg,  macaroni,  bread  and  butter,  tenderloin  steak, 
or  breast  of  chicken  may  gradually  be  added.  Water  should  be  pro- 
vided in  abundance,  and  acidulated  drinks,  sour  lemonade,  and  car- 
bonated waters  are  useful,  but  on  an  empty  stomach  only.  In  chronic 
purulent  conditions  fresh  fruits  _ and  green  vegetables  are  serviceable, 
both  for  their  antiscorbutic  and  their  laxative  effects.  Thus  lemonade, 
oranges,  baked-  apples,  and  stewed  prunes  are  recommended.  Fats 
are  also  especially  needed,  and,  when  the  patient  is  able  to  digest  them, 
should  be  liberally  provided  in  the  form  of  cream,  butter,  olive  oil,  or 
cod-liver  oil. 


no  DIET    AFTER    OPERATION 

A  work  of  this  sort  cannot  go  thoroughly  into  the  matter  of  food — 
its  preparation  and  administration — ^without  opening  the  great  subject 
of  cookery  and  being  led  afield  into  the  details  of  the  nursing  profession. 
I  believe  it  to  be  unwarrantable  during  convalescence  for  the  doctor 
to  undertake  to  prescribe  with  minute  exactitude,  irrespective  of  the  pa- 
tient's tastes,  the  kind  and  amount  of  food.  Every  patient  who  is  to  any 
degree  reasonable  knows  what  he  likes,  and  knows  what  seems  to  digest 
without  trouble  in  his  particular  case.  Each  individual  is,  in  a  sense,  a 
specialist  on  his  own  digestion.  He  has  information  on  the  matter  such 
as  no  other  person  can  have.  It  seems  reasonable,  also,  even  more 
perhaps  in  sickness  than  in  health,  to  give  heed  to  appetite  and  desire, 
since  it  is  probable  that  acquired  or  conventional  tastes  disappear 
under  these  conditions  and  rightful  instincts  are  more  likely  to  be  ex- 
hibited. It  is  better,  therefore,  in  surgical  convalescence  certainly  to 
let  the  patient  suggest  the  way  in  the  matter  of  food  and  drink,  always 
modified  and  limited  by  the  pathology  in  the  particular  case. 

The  Serving  of  Food — There  are  many  obvious  and  trite  con- 
siderations which  should  be  here  set  down.  While  the  patient  should, 
in  a  general  way,  be  consulted  as  to  what  he  wants,  nevertheless  the 
particular  ■  item  which  is  to  come  at  a  given  meal  may  well  be  served 
without  immediate  announcement — come,  in  a  measure,  as  a  surprise. 
In  judging  the  appetite  of  a  patient  it  must  be  remembered  that  the 
apparent  lack  of  desire  for  food  may  be  due  to  poor  cooking,  serving 
meals  unattractively  or  at  inopportune  moments,  or  to  the  selection  of 
articles  of  diet  not  to  the  patient's  taste.  It  is  the  function  of  the  nurse 
to  study  the  likes  and  dislikes  of  her  charge,  and  to  yield  to  them  so  far 
as  her  instructions  will  allow.  If  her  orders  are  vague  or  insufficient  to 
cover  any  condition  which  may  arise,  she  should  make  it  a  point  to  have 
them  made  clear  at  the  next  visit  of  the  physician.  The  doctor,  though 
he  should  on  his  part  be  explicit  in  his  directions  as  to  the  sort  and 
quantity  of  food  to  be  given  immediately  after  an  operation,  should 
provide  also  that,  on  the  one  hand,  the  patient  shall  not  starve  for 
want  of  food  which  is  agreeable  to  him,  or,  on  the  other  hand,  suffer 
from  overindulgence  in  a  diet  which  has  been  left  to  the  nurse's  discre- 
tion. 

Meals  should  be  served  at  regularly  appointed  intervals,  for  a  patient 
who  was  eager  to  eat  at  the  time  appointed  may  lose  interest  if  the  meal 
is  delayed.  Food  is  better  when  concentrated;  a  patient  easily  tires 
of  swallowing  dilute  victuals.  If  the  appetite  flags,  the  appearance  of 
some  new  or  unexpected  article  of  food  on  the  tray  is  very  pleasing. 
Food  should  be  served  either  hot  or  cold;    lukewarm  food  is  un- 


THE    SERVING    OF    FOOD  II9 

palatable.  The  cooking  and  preparation  of  food  should  be  done  where 
the  noise  and  odor  cannot  reach  the  patient.  The  tray  should  be  neat  and 
inviting,  the  china  attractive,  the  linen  clean,  and  the  food  fresh,  for  a 
person  confined  in  bed  becomes  fastidious  of  details  which  might  appear 
trivial  to  others.  The  quantity  of  food  offered  should  not  be  in  excess 
of  the  limit  of  his  capacity;  a  patient  may  take  half  from  a  cupful  of 
broth  and  reject  the  rest  with  disgust,  where  if  he  were  offered  a  cup 
half  full  he  would  drain  it  with  gusto.  The  tray  and  the  remnants  of 
the  meal  should  be  removed  at  once  after  the  patient  has  finished. 

A  person  who  has  become  accustomed  to  alcohol  from  excessive 
"  indulgence  is  very  apt  to  develop  delirium  tremens  (see  also  Chapter  XXX, 
p.  273)  in  the  course  of  a  few  days  after  receiving  a  severe  injury  or 
undergoing  an  operation,  even  though  he  has  indulged  in  no  stimulation 
for  some  weeks  previously.  When  the  delirium  is  marked  and  comes 
on  without  warning,  the  prognosis  is  generally  regarded  as  poor,  and  no 
means  should  be  omitted  which  can  be  of  aid.  Usually,  however,  it 
takes  some  days  to  develop,  and  the  patient  becomes  nervous  and  has 
^  well-defined  premonition  of  his  condition.  In  cases  of  emergency 
alcohol  should  always  be  used,  and  in  cases  where  it  is  suspected  that 
the  condition  is  about  to  develop,  it  may  be  wise  to  forestall  it  by  allow- 
ing a  certain  quantity  of  alcoholic  stimulant.  Some  surgeons  prefer 
to  treat  cases  not  acute  by  entirely  withholding  alcohol.  In  an  acute 
case  it  is  well  to  begin  by  emptying  the  stomach  and  bowel  by  purgation 
and  inducing  vomiting.  Large  quantities  of  water  should  be  given 
for  its  diuretic  action.  Carbonated  waters  and  ginger  ale  act  to  relieve 
the  craving  for  stronger  drink.  Next  to  rest,  the  most  important  object 
is  to  maintain  the  patient  by  sufficient  nourishment;  this  is  usually 
administered  with  some  difficulty,  as  the  appetite  for  food  is  usually 
entirely  wanting.  If  the  patient  is  comatose,  it  will  often  be  necessary 
to  resort  to  the  stomach- tube  or  rectal  enemas.  The  stimulating 
effect  of  the  alcohol  on  the  gastric  mucosa  may  be  simulated  by  the  ad- 
dition of  strong  spices,  ginger,  or  capsicum  to  the  diet.  The  diet  should 
be  liquid  or  semifluid  and  given  frequently  in  small  quantities.  The 
nervous  system  is  always  strengthened  and  soothed  by  abundant  nour- 
ishment. 

Special  diets  are  prescribed  where  indicated  under  special  opera- 
tions in  Part  II.  In  the  Appendix  are  given  a  number  of  food  recip-ss 
for  convalescents. 


CHAPTER  XII 

RECTAL  FEEDING 

The  use  of  the  absorptive  powers  of  the  mucous  membrane  of 
the  rectum  and  lower  bowel  in  the  nourishment  of  the  weak  and  sick 
comes  down  to  us  from  the  days  of  Galen.  It  is  comparatively  re- 
cently, however,  that  the  experimental  investigations  of  Voit,  Leube, 
Ewald,  and  others  have  established  rectal  feeding  on  a  scientific  basis. 
In  rectal  alimentation  we  now  have  a  practical  method:  first,  of  sup- 
plementary feeding,  in  cases  where  the  stomach  is  unable  to  digest  enough 
food  to  maintain  the  equilibrium  of  waste  and  repair;  second,  of  sus- 
taining life  independently  of  all  other  means  of  nourishment  for  a  short 
time. 

Rectal  feeding  may  be  indicated:  (i)  In  conditions  of  great 
weakness,  where  but  little  food  can  be  taken  by  mouth,  or  where  food  is 
not  retained.  In  patients  exhausted  by  a  serious  abdominal  operation 
rectal  feeding  is  a  temporary  expedient  of  great  value.  In  prolonged 
reflex  vomiting  after  an  anesthetic,  nutrient  enemas  may  be  our  sole  reli- 
ance. (2)  In  conditions  of  obstruction  to  the  entrance  of  food  into  the 
stomach,  such  as  paralysis  of  the  muscles  controlling  deglutition,  stric- 
ture of  the  esophagus,  foreign  bodies,  new-growths,  or  inflammatory 
conditions  of  the  mouth,  pharynx,  or  esophagus,  irritability  of  the 
alimentary  canal  from  ulceration  or  corrosion.  (3)  In  diseases  of  the 
stomach,  such  as  gastric  ulcer,  gastric  carcinoma  with  obstruction. 
(4)  In  conditions  of  shock,  coma,  or  delirium.  (5)  In  the  after-treatment 
of  operations  on  the  stomach,  gall-bladder,  or  small  intestine,  where 
peristaltic  activity  might  interfere  with  repair.  (6)  After  plastic  opera- 
tions on  the  face,  where  mastication  might  tear  out  stitches. 

The  technique  of  administering  a  nutrient  enema  is  as  fol- 
lows :  If  the  patient  can  be  moved  about,  he  is  brought  to  the  edge  of  the 
bed  and  placed  with  his  knees  drawn  up  toward  his  chest  in  an  exaggerated 
Sims  posture,  upon  his  left  side;  otherwise  he  is  to  lie  flat  on  his  back, 
with  knees  flexed.  In  either  case  the  buttocks  should  be  elevated  as 
much  as  is  comfortable  upon  a  small  hard  pillow;  in  this  way  gravity 
is  brought  to  aid  in  the  retention  of  the  enema.  A  long,  soft  rectal 
tube,  about  32  French  in  diameter,  with  open  end  and  two  lateral  eyes, 
120 


THE    TECHNIQUE    OF    ADMINISTERING    A   NUTRIENT   ENEMA        121 

is  employed;  in  children  an  ordinary  soft-rubber  catheter  may  be  used. 
The  tube  should  be  so  soft  that  it  will  not  do  damage  to  the  rectal  mucosa, 
and  yet  it  should  be  stiff  enough  so  as  not  to  be  likely  to  kink  or  double 
upon  itself  inside  the  ampulla.  Long  soft  tubes  coil  themselves  up, 
press  on  the  intestinal  wall,  and  stimulate  peristalsis  and  straining,  thus 
preventing  the  successful  administration  of  enemas.  To  its  end,  by 
means  of  a  short  piece  of  glass  tubing  which  is  to  serve  as  a  window, 
is  attached  about  a  foot  of  similar  rubber  tubing  coming  from  a  glass 
or  hard-rubber  funnel. 

The  tube  should  be  lubricated  sparingly  with  olive  oil  or  vaselin; 
glycerin  should  not  be  used,  as  it  excites  peristalsis.  The  funnel  is 
partly  filled  with  the  enema,  and  after  this  has  run  down  the  tube  to 
expel  the  air,  the  tube  is  pinched  and  introduced  through  the  anus.  Air 
in  the  tube  is  likely  to  be  driven  into  the  intestines,  where  it  will  set  up 
peristaltic  movements  and  lead  to  the  expulsion  of  the  enema.  If  the 
tube  is  passed  slowly  and  gently,  it  may  readily  be  carried  in  6  or  8 
inches.^  The  higher  up  the  fluid  goes,  the  more  extensive  is  the  ab- 
sorbing surface  that  it  comes  in  contact  with,  and  the  less  is  the  likeli- 
hood of  its  being  rejected.  (See  also  Chapter  XV,  p.  148.)  The 
veins  of  the  lower  rectum,  also,  empty  into  the  vena  cava  directly  and 
do  not  drain  through  the  liver.  To  prevent  the  tip  of  the  tube  from 
engaging  in  the  valves  of  Houston,  causing  the  tube  to  kink,  the  intro- 
duction should  be  slow  and  deliberate,  the  tube  meanwhile  being  rolled 
or  twisted  slightly  from  side  to  side  between  the  fingers. 

The  enema  should  be  poured  into  the  funnel  slowly,  and  the  funnel 
should  be  held  at  such  a  level  (not  over  2  feet)  above  the  level  of  the 
outlet  that  it  takes  about  ten  minutes  for  the  entire  quantity  to  pass  in. 
As  the  tube  is  withdrawn,  a  gauze  pad  is  held  up  against  the  anus  to 
prevent  the  enema  from  gushing  out.  The  patient  should  lie  quietly 
in  bed  for  an  hour  or  so  after  the  injection  and  should  be  told  to  try  to 
retain  the  enema.  If  it  appears  likely  that  the  fluid  will  leak  out,  a  pad 
should  be-  held  firmly  pressed  against  the  anus  for  fifteen  or  twenty 

^  Soper  (The  Colon-tube  and  High  Enema,  Jour.  Amer.  Med.  Assoc,  1909,  liii,  426) 
concludes  that  only  in  rare  cases  of  abnormal  development  of  the  sigmoid  is  it  possible  to 
introduce  a  soft-rubber  tube  higher  than  6  or  7  inches  in  the  rectum  without  it  bending  or 
coiling  upon  itself.  With  the  aid  of  the  sigmoidoscope  the  middle  of  the  sigmoid  can  be 
reached,  but  nothing  further.  He  substantiates  this  by  a.-ray  photographs.  The  short  tube, 
6  inches  in  length,  is  therefore  best  for  all  sorts  of  enemas:  (i)  When  water,  etc.,  is  intro- 
duced for  the  purpose  of  causing  fecal  evacuations;  (2)  when  retention  of  fluid  is  desired, 
as  in  administering  saline  solution,  oil,  nutrient  material,  etc.  The  attempt  to  pass  the  tube 
higher  into  the  bowels  is  not  only  unnecessary,  but  because  of  the  coiling  that  ine\itably 
occurs  such  a  manipulation  tends  to  produce  irritabihty  of  the  bowel.  This,  of  course,  will 
very  probably  cause  expulsion  of  the  fluid. 


122  RECTAL    FEEDING 

minutes  or  longer.     A  patient  is  likely  to  reject  enemas  at  first,  but  can 
soon  be  trained  to  retain  them  effectually. 

In  feeding  by  rectum  it  is  important  that  the  condition  of  the  rectum 
be  carefully  watched,  especially  if  it  is  likely  that  the  administration  of 
the  enemas  will  have  to  be  kept  up  for  more  than  a  few  days.  Patients 
have  been  maintained  on  rectal  feeding  exclusively  for  six  months  (Leube) 
and  ten  months  (Riegel),  but  four  to  six  weeks  may  be  accepted  as  the 
ordinary  limit,  and,  indeed,  in  most  cases  two  or  three  weeks  is  likely  to 
produce  irritation  and  mucous  diarrhea,  which  will  interfere  seriously  with 
absorption.  For  this  reason  all  sources  of  irritation  should  be  avoided. 
The  bowel  should  be  cleaned  of  mucus  and  fecal  matter  by  a  daily 
cleansing  enema,  best  given  in  the  morning,  some  time  before  the  first 
nutrient  of  the  day.  For  this  purpose  i  or  2  pints  of  saline  solution 
or  of  soapsuds  and  water  may  be  used  at  about  95°  F.  If  the  rectum 
is  inflamed,  i  pint  of  boracic  acid  solution  (i  dram  to  i  pint  of  water) 
may  be  used  once  or  twice  a  day  or  before  each  feeding;  if  there  is 
much  mucus,  sodium  bicarbonate  may  be  used  in  the  same  dilution. 
The  nutrient  should  not  be  given  until  all  the  wash-water  has  come 
away,  otherwise  the  enema  may  be  immediately  ejected. 

Opium,  about  10  minims  of  the  tincture,  is  frequently  added  to  the 
nutrients  as  a  routine  measure  to  prevent  peristalsis  and  thus  favor  the 
retention  of  the  enema.  If  enemas  are  rejected  at  first,  from  nervous 
irritability  of  the  rectum,  it  may  be  wise  to  use  opium  until  the  bowel  is 
accustomed  to  the  procedure,  when  it  becomes  unnecessary.  Opium 
may,  however,  interfere  somewhat  with  absorption,  and  for  this  reason, 
especially  if  the  use  of  enemas  will  have  to  be  continued  for  some  days, 
its  use  should  be  postponed,  if  possible,  until  it  becomes  necessary  on 
account  of  the  irritated  condition  of  the  mucous  membrane.  In  this 
case  the  opium  acts  better  if  administered  alone  or  mixed  with  2  ounces 
of  starch-water  one-half  hour  before  the  enema  is  due.  Red  wine 
is  frequently  employed  on  the  Continent  of  Europe  as  a  constituent  of 
nutrient  enemas.  The  small  percentage  of  alcohol  it  contains  is 
readily  absorbed,  and  its  astringency  and  slight  acidity  seem  to  favor 
retention  of  the  enema.  Thus,  a  little  claret  or  Burgundy  will  some- 
times act  as  efficiently  as  opium  for  this  purpose. 

Sometimes  the  presence  of  hemorrhoids  will  interfere  seriously  with 
rectal  feeding.  If  this  complication  occurs,  it  will  be  wise  to  use  a 
smaller,  softer  tube,  well  lubricated.  In  addition  to  local  treatment 
it  may  become  necessary,  on  account  of  pain,  to  apply  a  2  per  cent, 
solution  of  cocain  to  the  hemorrhoids  before  each  injection.  The 
presence  of  wicks  or  glass  or  rubber  drains  in  the  pelvis  or  vagina  may 


COMPOSITION   OF   NUTRIENT   ENEMAS  1 23 

interfere  materially  with  the  use  of  rectal  feeding.  It  should  also  be 
remembered  that  if  any  suturing  has  been  done  on  the  large  intestine, 
enemas  should  not  be  started  for  at  least  forty-eight  hours,  for  retro- 
peristalsis  may  carry  the  fluid  back  with  sufficient  force  to  tear  out  the 
stitches. 

Ordinarily,  6  ounces  (175  cc.)  of  fluid  is  given  every  four  hours.'  In 
some  cases  it  will  be  necessary  to  lessen  the  quantity  and  increase  the 
frequency  of  the  enemas;  4  ounces  (100  cc.)  may  be  given  every  two 
hours.  There  is  a  distinct  advantage,  however,  in  favorable  cases  in 
giving  a  larger  quantity  less  often.  If  given  slowly,  8  or  10  ounces  (250- 
300  cc.)  may  be  retained,  and  the  patient  will  suffer  less  from  thirst 
and  there  will  be  less  likelihood  of  inflammatory  changes  being  set  up 
in  the  rectum.  Such  an  enema  need  be  given  only  three  or  four  times 
a  day,  which  is  of  some  importance  in  gastric  cases,  for  it  has  been 
shown  that  each  injection  stimulates  gastric  secretion. 

The  sensations  of  hunger  and  thirst  may  be  annoying  to  a  patient 
who  is  being  started  on  rectal  feeding.  They  rarely  persist  after  twenty- 
four  hours;  the  thirst  may  be  met  by  additional  enemas  of  saline  solu- 
tion or  of  plain  water  once  or  twice  a  day  if  the  patient  cannot  take 
water  by  mouth.  All  enemas,  to  be  retained,  should  have  a  tempera- 
ture of  95°  F.,  or  about  body  temperature.  Fluids  much  warmer  or 
cooler  than  this  are  likely  to  set  up  a  peristalsis,  which  will  lead  to  their 
ejection. 

The  material  for  the  enema  should  be  selected  with  a  view  to  ab- 
sorbability and  absence  of  irritating  qualities;  substances  which  theo- 
retically should  be  readily  absorbed,  like  the  peptones,  may  be  so  irritat- 
ing that  they  are  not  retained;,  other  substances,  which  are  absorbed 
only  in  small  proportion,  if  at  all,  may  interfere  with  absorption  of  the 
other  elements  of  the  enema  by  causing  irritation,  as  the  starches,  or 
by  forming  a  coating  over  the  mucosa,  like  unemulsified  fats.  Many 
extended  metabolic  experiments  on  human  beings  have  been  carried  on 
with  a  view  to  determining  the  relative  absorbability  of  the  various 
classes  of  food-stuffs,  and,  although  these  show  woeful  lack  of  agree- 
ment, I  will  attempt  to  summarize  them: 

Proteids  are  usually  supplied  in  the  form  of  egg-albumen,  milk, 
beef-juice,  and  peptones.  Egg-albumen  and,  indeed,  all  proteids  not 
predigested  are  better  absorbed  if  salt  is  added  in  the  proportion  of  15 
gr.  per  egg.  Milk,  if  peptonized  and  not  too  rich  in  cream,  is  very 
satisfactory,  and  is  commonly  used  as  a  basis  of  nutrient  enemas.  Beef- 
juice  raw  is  absorbed  to  a  certain  degree,  but  had  better  be  peptonized. 
Leube  has  used  meat  chopped  up  with  one-third  its  weight  of  fresh 


124  RECTAL    FEEDING 

pancreas,  on  the  theory  that  the  meat  is  digested  within  the  rectum 
and  the  products  absorbed.  Except  in  his  hands,  however,  the  method 
has  not  been  found  wholly  satisfactory,  and  meat,  if  used,  had  better  be 
predigested  before  introduction  by  the  use  of  fresh  extract  of  pancreas. 
A  glycerin  extract  should  not  be  used  in  any  amount  on  account  of  the 
aperient  action  of  the  glycerin.  Commercial  peptone,  2  or  3  oz.  in  8  or  10 
oz.  of  water,  will  often  be  well  absorbed,  especially  in  the  presence  of  a 
little  alcohol.  It  has  the  disadvantage  of  being  expensive  and  it  may 
set  up  irritation.  On  the  whole,  proteids  are  but  poorly  absorbed,  the 
proportion  varying  and  depending  apparently  on  individual  peculiarity 
and  not  on  the  amount  injected.  Roughly  speaking,  it  may  be  said 
that  in  favorable  cases  35  per  cent,  of  the  amount  injected  is  absorbed 
if  predigested;   if  not  predigested,  about  20  per  cent. 

Fats  are  usually  given  as  yolks  of  egg,  milk,  cream — natural  emulsi- 
fications.  Unemulsified  fats  are  but  slightly  absorbed  and  are  useless. 
Olive  oil  may  be  emulsified  by  saponifying  a  small  portion  and  shaking 
all  together.  Fat  is  important,  in  that  it  seems  to  lessen  the  loss  of 
tissue  nitrogen.  Emulsified  fat,  in  small  quantities,  is  slowly  absorbed 
in  direct  proportion  to  the  quantity  injected — about  25  per  cent. 

Carbohydrates  are  supplied  in  the  form  of  glucose  (grape-sugar  or 
dextrose),  flour,  or  starch.  Pure  glucose,  in  10  to  20  per  cent,  solution 
in  water,  forms  a  nutritious  and  easily  absorbed  element.  The  com- 
mercial glucose  should  be  avoided,  as  it  may  contain  traces  of  sulphuric 
acid  and  arsenic,  either  of  which  might  give  rise  to  irritation.  About 
80  per  cent,  is  absorbed.  Boiled  flour  or  starch  or  raw  starch  is  some- 
times added  in  small  quantity  for  its  nutritive  value  and  to  thicken  the 
fluid. 

Alcohol  diluted  may  be  added  in  small  quantity  to  any  enema,  both 
for  its  stimulant  action  and  to  promote  absorption  of  the  nutrient. 
Whisky,  brandy,  or  any  red  wine  may  be  used,  being  careful  not  to 
cause  precipitation. 

Salt,  up  to  I  per  cent.,  facilitates  absorption  of  the  enema,  especially 
if  it  contains  proteids;  a  large  proportion  causes  irritation.  To  any  acid 
mixture  such  as  is  likely  to  result  if  peptones  are  used,  enough  sodium 
bicarbonate  should  be  added  to  make  the  reaction  slightly  alkaline. 

Drugs,  as  indicated,  may  be  administered  by  rectum,  by  adding 
them  to  an  enema,  providing  they  do  not  cause  precipitation. 

Proprietary  preparations  have  been  variously  recommended  for 
purposes  of  rectal  feeding.  Among  these  may  be  mentioned  liquid 
peptonoids,  bovinin,  malted  milk,  nutrose,  somatose,  maltine,  plasmon, 
proton,  eucasin,  sanatogen,  panopepton. 


FORMULAS    FOR    NUTRIENT    ENEMAS  12$ 

Rectal  suppositories  are  now  being  supplied  by  manufacturers  to 
replace  the  ordinary  method  of  feeding  by  injection.  They  are  made 
of  predigested  and  evaporated  milk,  or  meat- juice,  and  cocoa-butter. 
They  are  convenient  on  account  of  the  readiness  with  which  they  are 
administered  and  retained,  but  where  the  patient  is  being  fed  by  rectum 
alone,  they  are  not  practicable  on  account  of  the  small  amount  of  material 
they  supply.  Containing  so  large  a  proportion  of  fat,  and  being  placed 
so  low  down  in  the  bowel,  it  is  probable  that  only  a  small  percentage 
of  the  food-elements  is  absorbed.  Alternate  suppositories  of  meat  and 
milk  may  be  given  every  two  hours. 

In  many  patients  the  institution  of  rectal  feeding  is  marked  by 
satisfaction  of  hunger  and  thirst,  mental  relief,  and  apparent  mainten- 
ance of  general  condition  or  even  increase  in  weight.  Nevertheless, 
rectal  feeding  is  at  best  a  poor  substitute  for  feeding  by  mouth,  and  in 
the  most  favorable  cases  the  patient  is  being  subjected  to  partial  starva- 
tion, for  it  is  now  generally  agreed  that  the  limit  of  absorption  per 
rectum  is  about  one-fourth  the  nourishment  required  to  maintain  meta- 
bolic equilibrium  in  normal  persons.  Gain  in  weight,  where  it  occurs, 
is  due  to  the  rapid  absorption  of  water  to  satisfy  the  marked  depletion 
of  the  tissues  which  ensues  after  severe  hemorrhage  or  protracted  vomit- 
ing. Some  of  the  beneficial  effects  of  nutrient  enemas  may  be  assigned 
to  the  psychic  influence  of  the  procedure.  Where  rectal  feeding  is  the 
sole  source  of  nourishment,  the  composition  of  the  enema,  the  technique 
of  its  administration,  and  the  condition  of  the  rectum  should  receive 
the  constant  and  particular  attention  of  the  surgeon  himself. 

FORMULAS  FOR  NUTRIENT  ENEMAS 

The  egg  and  sugar  enema  (Ewald)  is  efficient  and  commonly  em- 
ployed. Boil  a  teaspoonful  or  two  of  starch  or  wheat  flour  in  a  half- 
cupful  of  20  per  cent,  solution  of  glucose  (grape-sugar)  and  add  a 
wineglassful  of  claret.  After  this  has  cooled  sufficiently  to  prevent  the 
coagulation  of  the  albumin,  stir  in  slowly  two  or  three  eggs  which  have 
been  beaten  up  smooth  with  a  tablespoonful  of  water. 

Egg  and  milk:     3  eggs,  beaten,  in 

Peptonized  milk 3  oz.  (250  cc); 

Salt 2  or  3  pinches  (2  gm.). 

Sugar  and  milk:    Grape-sugar ' 2  oz.  (60  gm.); 

Peptonized  milk. 8  oz.  (250  cc). 

Leube:     Milk 3  oz.  (250  cc); 

Peptone 2  oz.  (60  gm.). 


125  RECTAL    FEEDING 

Riegel:     Milk ..3  oz.  (250  cc); 

Egg 2  or  3; 

Salt 2  or  3  pinches; 

Red  wine i  tablespoonful. 

Boas:     Milk \ 8  oz.  (250  cc); 

Yolk  of  2  eggs 
Pinch  of  salt 

Red  wine . , . . .  i  tablespoonful; 

Starch  or  flour i  tablespoonful. 

Boyd:     Yolks  of  2  eggs 

Pure  dextrose i  oz.  (30  gm.) ; 

Salt 7  gr-  (5  gm.); 

Peptonized  milk  to 10  oz.  (300  cc). 

Baumgarten:     Dry  peptone 

Sugar  of  milk  (of  each) i  oz.; 

Alcohol I  oz.; 

Tincture  of  opium 10  drops; 

Water  to  make 9  oz. 

The  following  formula  has  been  recommended  by  Dr.  Ehrenfried: 
Separate  the  whites  and  yolks  of  3  eggs,  add  the  whites  to  200  cc. 
of  milk,  and  peptonize  it.     Stir  in  the  beaten  yolks.     Add  2  oz.  of  pure 
grape-sugar  dissolved  in  80  cc.  of  water,  20  cc.  of  red  wine,  and  2  pinches 
of  salt: 

•     Milk,  200  cc 146  calories; 

3  eggs 200 

2  oz.  of  grape-sugar 246        " 

2  pinches  of  salt 
20  cc.  red  wine. 

592  calories. 

References 
Thompson,  Practical  Dietetics,  1902. 

Friedenwald  and  Ruhrah,  Diet  in  Health  and  Disease,  1909 . 
Boyd,  Rectal  Alimentation,  Trans.  Med.  Chir.  Soc  of  Edin.,  xxv,  1906,  126. 
Moore,  F.  C,  Rectal  Feedings,  Practitioner,  1907,  Ixxix,  668. 


CHAPTER  XIII 


GAVAGE  AND  OTHER  FORMS  OF  ARTIFICIAL  FEEDING 

Gavage  is  the  name  given  to  the  method  of  feeding  a  patient  by 
pouring  liquids  through  a  tube  into  the  stomach.  It  is  not  commonly 
used  in  postoperative  treatment,  but  it  may  be  indicated: 

1.  In  infants  or  young  children  who  persistently  refuse  food,  or  are 
too  weak  to  take  nourishment  in  sufficient  quantity. 

2.  As  an  alternative  for  rectal  feeding  in  persistent  vomiting  after 
an  anesthetic,  provided  there  is  no  stomach  lesion. 


Fig.  40. —  Lavage,  First  Step. 
Introduction  of  tube. 


Fig.  41. — Lavage,  Second  Step. 

Tube   in   stomach.     Wash-water    being   poured    into 

funnel. 


3.  As  a  method  of  forced  feeding  in  acute  infections,  coma,  delirium, 
insanity. 

4.  Where  swallowing  is  interfered  with,  as  after  operations  on  the 
head  and  neck,  in  diseases  of  the  mouth,  lockjaw,  or  postdiphtheritic 
paralysis. 

The  technique  and  apparatus  are  the  same  as  for  gastric  lavage.  A 
highly  polished    soft-rubber  tube,  about   30  to  32  French,  should  be 

1'27 


128 


GAVAGE   AND   OTHER   FORMS    OF   ARTIFICIAL   FEEDING 


selected,  of  medium  flexibility,  with  a  conic  end— having  two  open- 
ings, one  at  the  end  and  another  on  the  side,  about  f  inch  above.  In 
children  an  ordinary  soft-rubber  catheter  may  be  used,  about  21  to  25 
French,  according  to  age.  It  should  be  attached  by  a  short  piece  of 
glass  tubing,  which  serves  as  a  window,  to  a  rubber  tube  coming  from 
a  glass  or  hard-rubber  funnel.  As  a  lubricant,  glycerin,  olive  oil,  butter, 
plain  warm  water,  or  ice-water  may  be  used. 

The  patient  should  be  sitting  or  lying  in  a  comfortable  position,  the 
head  not  tilted  back  or  inclined  to  one  side  or  the  other.  He  should  be 
directed  to  breathe  slowly  and  deeply.     A  child  might  better  be  wrapped 

r-^m^ — w,  in  a  sheet  and  held  seated  on  the 
W^^  nurse's  lap,  with  its  head  sup- 
^^Hm  ported  on  her  shoulder,  or  laid  flat 
on  its  back  on  a  table.  The  tube 
should  be  held  some  inches  from 
the  tip,  and  with  one  motion  it 
should  be  passed  rapidly  over  the 
median  line  of  the  tongue  down 
through  the  pharynx  into  the 
esophagus.  It  is  not  necessary  to 
hold  a  finger  in  the  mouth;  as 
soon   as   the   tip  strikes  the  pos- 

/terior  wall   of   the    pharynx    the 
patient   will   begin  to    retch   and 
^    '  gag,  but  if  he  will  make  several 

k  '  ■  '    rapid  swallowing  movements  and 

g.,.  '  can  resist  the  impulse  to  seize  the 

r^.  tube  and  pull  it  out,  all  will  be 

well.  If  the  tube  is  held  too 
near  the  tip,  the  tip  will  be  in 
contact  with  the  pharyngeal  wall 
while  the  operator  is  shifting  his  hold,  and  the  tube  will  probably  be 
rejected.  In  the  unconscious  or  delirious,  as  well  as  in  children  over 
two  years  of  age,  it  is  advisable  to  use  a  mouth-gag.  In  the  uncon- 
scious, also,  one  must  be  sure  by  the  patient's  respiration  that  the 
tube  is  in  the  stomach  and  not  the  trachea  before  fluid  is  poured  in. 
Some  nervous  patients  will  experience  respiratory  embarrassment 
the  first  time  the  tube  is  ernployed.  This  can  always  be  controlled  if 
the  patient  will  but  breathe  deeply  and  slowly  while  the  tube  is  being 
passed.  Patients  readily  get  accustomed  to  the  tube.  It  should  be 
used  with  caution  in  persons  with  cardiac  disease. 


Fig.  42. — Lavage,  Third  Step. 
Suction  and  siphonage. 


NASAL    FEEDING  1 29 

The  tube  is  passed  to  the  point  where  hquid  is  found  to  flow  in 
without  obstruction,  usually  about  22  inches  to  the  line  of  the  teeth 
in  the  adult.  If  there  is  any  gas  on  the  stomach,  it  should  be  allowed 
to  escape  by  elevating  the  funnel  before  the  feeding  is  poured  in.  After 
the  liquid,  in  quantity  proper  to  the  age  of  the  patient,  has  passed  in, 
the  tube  is  pinched  tightly  and  withdrawn  rapidly  with  one  sweep. 
A  slow  withdrawal  of  the  tube,  or  the  tricklings  of  the  last  drops  of  the 
fluid  from  the  tube  in  its  upward  passage,  may  be  sufficient  to  excite 
reflex  vomiting.     If  the  fluid  is  vomited,  the  feeding  should  be  repeated. 

The  materials  ordinarily  employed  in  feeding  through  a  stomach- 
tube  are  milk,  eggs,  meat-juices,  or  broths.  If  indication  exists,  the 
meat  broth  or  milk  may  be  peptonized.  A  common  feeding  through  a 
stomach-tube  in  an  adult  is  two  eggs  (beaten),  stirred  into  ij  pints 
of  warmed  milk,  with  a  pinch  of  salt,  administered  four  times  daily, 
or  alternated  with  beef-juices  or  chicken  broth,  thickened  with  tapioca 
or  sago. 

Care  should  be  taken,  first,  that  the  fluid  is  not  hot  enough  to  burn 

the  stomach;  and,  second,  that  the  capacity  of  the  individual  stomach  is 

not  exceeded. 

NASAL  FEEDING 

Nasal  feeding  is  a  substitute  for  gavage  which  is  employed  rarely 
except  in  children.  It  is  indicated  in  those  cases  where  the  stomach- 
tube  cannot  be  passed  by  mouth  on  account  of  ulcerative  stomatitis, 
after  operations  about  the  mouth,  after  tracheotomy,  where  great  ner- 
vous excitement  is  induced,  and  in  children  in  general. 

The  simplest  method  is  that  of  pouring  the  fluid  nourishment  from 
a  spoon  into  the  nostril.  This  is  employed  in  comatose  states,  and  it 
obviates  the  necessity  of  opening  the  mouth.  A  teaspoonful  should  be 
given  at  a  time,  making  sure  the  dose  is  swallowed  before  it  is  repeated. 
If  the  patient  is  lying  back,  the  fluid  will  trickle  down  the  posterior 
pharyngeal  wall  and  excite  the  reflex  of  deglutition.  Any  excess  of 
fluid  will  be  regurgitated  through  the  other  nostril  and  the  likelihood 
of  choking  is  slight. 

It  is  usually  better,  however,  to  use  the  distal  half  of  a  small-sized 
soft-rubber  catheter  attached  to  a  small  glass  funnel.  This  is  lubri- 
cated with  olive  oil  or  vaselin,  introduced  gently  into  one  nostril,  and 
held  in  place  while  the  fluid  is  poured  in.  Just  sufficient  is  poured 
in  at  a  time  to  allow  the  child  to  swallow.  The  patient  should  be  wound 
in  a  sheet,  so  that  he  may  not  struggle,  and  held  firmly  on  his  back.  In 
either  of  these  methods  there  is  some  danger  of  setting  up  irritation  or 
inflammation  of  the  middle  ear  by  way  of  the  Eustachian  canal. 
9 


130  GAVAGE   AND    OTHER   FORMS    OF   ARTIFICIAL   FEEDING 

It  is  safer,  therefore,  to  pass  the  tube  through  the  nose  into  the 
esophagus  and  stomach.  If  the  patient  is  lying  flat,  with  his  head  in 
the  median  hne,  there  wiU  be  no  difficulty  in  passing  a  soft,  small- 
sized  stomach-tube,  well  lubricated,  along  the  floor  of  the  nose  into 
the  esophagus.  Before  pouring  in  the  feeding  it  must  be  seen  that 
the  patient  is  breathing  freely  and  that  the  tube  is  not  in  the  lar}Tix. 
This  is  the  only  method  now  used  and  advised  by  Dr.  John  H.  McCol- 
lom  at  the  Boston  City  Hospital,  South  (Infectious  Diseases)  Depart- 
ment. 

SUBCUTANEOUS   FEEDING 

The  method  of  introducing  fluid  nourishment  into  the  system  by 
subcutaneous  injection  has  not  yet  been  generally  accepted,  although 
it  has  been  practised  since  1850.  In  desperate  emergencies,  where 
conditions  have  been  such  that  nourishment  could  not  be  administered 
either  by  mouth  or  rectum,  solutions  of  food  substances  have  been 
injected  under  the  skin,  directly  into  the  veins  of  the  arm,  or  into  serous 
cavities  with  some  apparent  success.  In  animals,  olive  oil  has  been 
used  in  this  way,  as  well  as  diluted  milk  and  solutions  of  sugar  or  al- 
bumin, and  absorbed  without  ill  effects. 

The  food  material  selected  must  be  a  fluid  which,  first,  needs  no 
digestion,  and,  second,  which  can  be  sterilized  by  boiling.  The  more 
closely  it  simulates  blood  in  osmotic  tension,  the  less  irritation  will  there 
be  at  the  site  of  injection.  Pure  glucose  in  5  per  cent,  solution  in  dis- 
tilled water  fulfils  these  conditions  well  and  may  be  given  freely.  Olive 
oil  has  been  recommended  in  doses  of  100  cc.  injected  in  divided  por- 
tions into  various  parts  of  the  body.  It  should  be  sterilized  by  heat. 
It  absorbs  slowly  and  causes  some  pain,  and  the  danger  of  fat  embolus 
must  not  be  overlooked.  Milk  and  peptone  solution  have  also  been 
used  in  doses  of  6  or  8  oz. 

The  injection  must  be  made  with  all  precautions  as  to  asepsis.  A 
sterile  glass  syringe,  such  as  is  commonly  called  an  antitoxin  s}Tingej 
is  adaptable  for  the  purpose.  The  injection  should  be  made  slowly, 
and  once  or  twice  a  day  is  sufficient.  The  fluid  should  be  at  blood 
heat. 

In  view  of  the  well-known  efficacy  of  the  subcutaneous  method  of 
supplying  water  to  the  system  where  the  tissues  have  been  deprived 
of  this  constituent,  in  persistent  vomiting,  in  shock  from  loss  of  blood, 
in  cholera,  as  well  as  in  toxemias,  it  seems  probable  that  the  successes 
reported  by  some  of  those  who  first  used  this  method  of  feeding  were 
due  in  large  part  to  the  introduction  of  fluid  without  reference  to  its 
food  value. 


AFTER   LARYNGEAL    OPERATIONS  I3I 


FEEDING  IN  GASTRIC  FISTULA 


After  a  gastric  fistula  has  been  established  feeding  may  be  started, 
if  necessary,  within  a  few  hours.  For  this  purpose  a  glass  funnel  should 
be  attached  to  the  drainage-tube  leading  to  the  stomach  and  small 
amounts  of  liquid  poured  in.  An  egg  beaten  up  in  a  glass  of  milk,  with 
a  pinch  of  salt,  may  be  given  every  two  hours.  The  patient  should  be 
kept  upon  mush  and  soft  solids  for  about  a  week  after  operation. 

If  the  operation  has  been  performed  for  non-malignant  stenosis, 
the  digestive  powers  of  the  stomach  suffer  very  little,  and  the  patient 
can  be  given  solid  food,  such  as  meat  chopped  into  bits,  which  may 
be  pushed  down  the  tube  with  a  glass  rod.  At  the  end  of  three  weeks 
the  patient  may  be  put  on  his  normal  diet — potatoes,  meat,  bread 
and  butter,  vegetables— which  he  masticates,  introduces  into  the  tube 
or  funnel  from  his  mouth,  and  pushes  along  into  his  stomach  with  a 
rod. 

In  cases  of  carcinoma  food  should  be  given  which  makes  the  least 
demand  on  the  digestive  powers  of  the  stomach  and  which  is  rapidly 
passed  on.  Peptonized  milk  may  be  used  and  solutions  of  peptone  or 
glucose.  The  patient,  however,  is  usually  extremely  desirous  of  being 
allowed  to  chew  and  taste  his  food,  and  for  this  purpose  gruels,  soft- 
boiled  eggs,  and  toast  may  be  given. 

AFTER  LARYNGEAL  OPERATIONS 

Tracheotomy  is  performed  for  obstructions  of  various  kinds,  such 
as  foreign  bodies, — a  tin  whistle  or  a  piece  of  meat, — edema  of  the  glottis, 
new-growths,  accumulation  of  diphtheritic  membrane,  Ludwig's  angina. 
The  presence  of  the  tube  is  well  borne,  as  a  rule,  and  interferes  in  no 
way  with  deglutition  after  the  patient  has  become  accustomed  to  its  pres- 
ence, provided  it  be  of  the  right  size  and  well  adjusted.  I  know,  for 
instance,  of  one  patient,  a  well-nourished  negro,  who  has  worn  a  tube 
for  complete  obstruction  for  twelve  years.  At  lirst,  apprehension  on  the 
part  of  the  patient  may  be  a  factor  in  making  the  feeding  a  matter  of 
some  difficulty.  If  the  patient  be  propped  up  by  pillows  to  a  sitting 
posture  and  liquids  given  by  means  of  the  feeder,  to  the  spout  of  which 
a  rubber  tube  may  be  attached,  the  difficulty  is  usually  readily  overcome. 
Until  the  patient  can  begin  to  take  semisolids,  fluids  should  be  given 
in  small  quantities  at  frequent  intervals.  Should  the  patient  resist, 
or  should  his  condition  be  such  as  to  preclude  any  cooperation  on  his 
part,  and  feeding  be  imperative,  nasal  feeding  should  be  used  without 
hesitation  or  delay. 


132  GAVAGE    AND    OTHER    FORMS    OF    ARTIFICIAL    FEEDING 

When  intubation  of  the  larynx  has  been  performed,  usually  for 
diphtheria,  the  patient  is  apt  to  find  trouble  in  swallowing  without  draw- 
ing food  into  the  trachea.  It  is  difficult  to  close  the  epiglottis  with  the 
tube  in  position,  or  to  draw  up  the  larynx  beneath  the  root  of  the  tongue 
to  the  extent  which  should  occur  in  normal  deglutition,  and  hence  fluid 
food  in  particular  is  liable  to  trickle  through  the  tube  into  the  trachea, 
exciting  violent  dyspnea  and  spasms  of  coughing.  Semisolid  food  or 
solid  food,  such  as  mush  eggs,  junket,  cream,  gelatin,  rice,  tapioca, 
ice-cream,  is  more  liable  to  glide  over  the  instrument  without  being 
sucked  in  through  it  during  inspiration.  \^ery  young  infants,  who  are 
dependent  upon  a  milk  diet,  can  swallow  best  if  laid  upon  the  back 
across  the  nurse's  lap  with  the  head  downward,  supported  below  her 
knees.  While  in  this  position  the  bottle  is  given.  Regurgitation 
through  the  nose  may  occur,  but  that  is  of  little  moment  compared  with 
the  accident  of  inhaling  milk  through  the  tube  into  the  lungs.  Older 
children  and  adults  can  usually  learn  to  swallow  well  while  wearing 
the  tube  with  a  little  practice  in  holding  the  head  and  the  avoidance  of 
inspiration  at  the  moment  of  swallowing.  Otherwise,  when  neces- 
sary, the  passage  of  the  esophageal  tube  may  be  resorted  to,  though 
this  irritates  the  throat  and  may  spread  the  diphtheritic  membrane  along 
the  esophagus.  Where  the  dyspnea  is  not  extreme,  the  tube  may  be 
removed  while  the  child  takes  nourishment,  or,  indeed,  it  may  be  well 
to  resort  to  rectal  alimentation  for  a  few  days  to  avoid  the  necessity  of 
swallowing  while  the  tube  is  in  situ. 


CHAPTER  XIV 
CATHETERIZATION;  CYSTITIS;  CATHETER  FEVER 

CATHETERIZATION 

Difficulty  with  urination  is  frequently  the  source  of  much  dis- 
comfort after  operation.  Sometimes  the  nature  of  the  operation  seems 
to  be  the  deciding  factor;  operations  about  the  rectum  and  for  hernia 
are  hkely  to  be  followed  by  retention.  It  frequently  seems  to  be  a  sort 
of  neurosis,  and  as  such  is  particularly  liable  to  occur  in  nervous  per- 
sons, especially  after  celiotomy.  Oftentimes  the  position  of  the  patient 
in  bed  accounts  for  the  difficulty  in  urination,  as  any  one  who  attempts 
for  the  first  time  to  urinate  while  lying  upon  his  back  can  testify. 

Everything  which  can  be  done  to  encourage  the  patient  to  urinate 
spontaneously  should  be  tried  before  a  catheter  is  employed.  If  the 
patient  is  conscious  and  intelligent,  nothing  should  be  done  until  he 
Calls  attention  to  his  desire  to  urinate,  then,  if  difficulty  is  experienced, 
simply  turning  the  patient  on  his  side,  or  allowing  him  to  stand,  sup- 
ported, beside  the  bed,^ — if  the  nature  of  the  operation  has  been  such 
as  to  make  this  allowable, — is  likely  to  give  relief.  After  the  patient 
has  once  urinated,  there  will  be  no  necessity  for  calling  the  catheter 
into  requisition. 

Ordinarily  the  urinary  secretion  is  inhibited  to  a  certain  degree  by 
anesthesia,  so  that,  as  a  rule,  after  celiotomy  the  patient  may  be  allowed 
to  go  sixteen  to  twenty  hours  before  resorting  to  the  catheter.  When 
the  catheter  is  being  used  as  a  routine,  once  every  eight  hours  is  fre- 
quent enough.  This  routine,  once  established,  should  not  be  continued 
indefinitely,  but,  on  account  of  the  danger  of  cystitis,  the  patient  should 
be  made  as  early  as  possible  to  realize  that  he  must  take  care  of  his 
own  bladder  function. 

If,  during  the  operation,  the  bladder  has  been  opened,  or  its  coats 
weakened  in  any  w^ay,  or  if  adhesions  between  the  bladder  and  other 
organs  have  been  separated,  distention  should  be  avoided.  Accord- 
ingly, the  catheter  should  be  passed  six  hours  after  operation  and  every 
four  or  six  hours  subsequently,  or  else  permanent  drainage  should  be 
instituted  by  tying  in  a  catheter. 

A  good  nurse  will  be  competent  to  pass  a  catheter  through  the 
normal  urethra,  male  or  female,  and  into  the  bladder,  with  skill  and 

133 


134  catheterization;  cystitis;  catheter  tever 

gentleness.  Lack  of  dexterity  and  of  care  in  the  performance  of  this 
responsible  duty  is  shown  immediately  by  the  pain  which  is  caused 
the  patient,  and  later,  possibly,  by  a  cystitis.  A  surgeon  should  never 
order  a  nurse  to  pass  a  catheter  until  he  is  sure  that  she  is  able  to  do  it 
without  causing  pain  or  injury  to  the  urethra  and  in  an  aseptic  manner. 
In  catheterizing  women  the  female  catheter  of  glass  should  be  used. 
This  can  be  readily  washed  clean  and  boiled.  It  should  be  sterilized 
before  using,  and  should  be  handled  only  by  the  sterile  hands  of  the 
nurse.  The  practice  of  passing  a  catheter  under  the  bedclothes,  by 
the  sense  of  touch,  is  mentioned  only  to  be  condemned.  It  is  unintel- 
ligent and  dirty.  The  parts  should  be  exposed  and  the  meatus  urin- 
arius  should  be  sponged  with  weak  corrosive.     Then,  with  the  fingers 


Fig.  43. — Catheterization  or  the  Female. 
Cleansing  the  parts. 

of  the  left  hand  separating  the  labia,  the  catheter  can  be  introduced 
painlessly,  without  fumbling,  and  without  danger  of  carrying  in  in- 
fective matter  from  the  bedclothes,  anus,  or  vagina. 

For  the  male  urethra,  the  best  catheter  for  routine  use  and  in  in- 
experienced hands  is  that  of  soft  rubber.  This  ordinarily  can  readily 
be  introduced  if  properly  lubricated,  and  with  it,  it  is  practically  im- 
possible to  injure  the  patient.  It  is  relatively  easy  of  sterilization — 
by  washing  thoroughly  in  soap  and  water  and  then  boiling  for  three 
to  five  minutes.  It  stands  boiling  very  well,  but  gradually  loses  its 
resiliency,  when  it  should  be  discarded.  If  it  is  thin  walled  and  very 
flexible,  it  sometimes  gives  trouble.  Size  22  or  24  French  is  convenient 
in  the  normal  urethra.     If  difficulty  is  experienced  at  all,  it  is  at  the  neck 


CATHETERIZATION  I35 

of  the  bladder,  where  spasm  of  the  sphincter  prevents  the  catheter  from 
entering.  If  continuous  hght  pressure  is  exerted  on  the  catheter,  the 
spasm  will  gradually  yield  and  allow  the  catheter  to  proceed. 

Catheters  of  metal  are  sometimes  advantageous  and  even  necessary, 
as,  for  instance,  in  prostatic  cases.  They  are  readily  and  completely 
sterilizable.  A  polished  silver  catheter  is  probably,  in  skilled  hands, 
the  most  agreeable  of  all  catheters  to  the  patient.  On  account  of  the 
possibility  of  tearing  the  urethra,  however,  its  use  should  never  be 
allowed  except  by  trained  and  competent  persons.  Ordinarily,  the  gum- 
elastic  or  silk-webbing  catheters,  which  carry  stilets  and  can  be  bent  to 
maintain  any  curve  after  being  immersed  in  hot  water,  or  the  "coude" 
or  elbowed  catheter,   may  be  employed  instead   in  prostatics.     The 


Fig.  44. — Catheterization  of  the  Female. 
Passing  the  catheter. 

disadvantage  of  this  form  of  coated  catheter  is  that  with  it  com- 
plete sterilization  is  difficult.  The  ordinary  English  webbing  catheter 
is  roughened  and  spoiled  by  boiling ;  some  of  the  better  grade  of  French 
webbing  catheters  can  be  boiled  carefully  a  number  of  times  without 
injury.  The  means  of  sterilizing  the  cheaper  grades  which  is  ordinarily 
employed  is  a  soap-and-water  wash,  followed  by  a  prolonged  soak  in 
an  antiseptic  solution.  The  only  adequate  means  of  sterilizing  these, 
catheters  is  in  the  metal  containers  which  have  recently  been  placed 
upon  the  market  in  which  pastils  of  formalin  are  burned.  The  catheter 
should  be  kept  in  contact  with  the  vapor  for  twenty-four  hours  or  longer; 
before  using  it  should  be  washed  off  in  sterile  water  or  boric  acid  solu- 
tion, that  the  urethra  may  not  be  irritated  by  the  formalin. 


136  catheterization;  cystitis;  catheter  fever 

Whatever  catheter  is  employed,  particular  care  should  be  taken  that 
it  is  absolutely  sterile.  Aseptic  precautions  should  be  taken  with  re- 
gard to  the  hands  of  the  physician  or  nurse  and  the  penis.  The  fore- 
skin should  be  drawn  back  and  the  glans  penis  and  the  meatus  should 
be  washed  off  with  weak  carbolic  or  corrosive  solution.  Boric  acid 
solution  is  too  weak. 

For  lubrication,  one  of  the  sterile  and  somewhat  antiseptic  com- 
mercial "artificial  mucus"  preparations  should  be  used.  They  come 
put  up  in  wide-mouthed  jars,  into  which  the  tip  of  the  sterile  catheter 
can  be  inserted,  or  in  squeeze  tubes,  from  which  a  sufficient  quantity 
of  the  lubricant  may  be  projected  on  the  tip  of  the  instrument.  With 
care  in  using  the  sterility  can  be  maintained  indefinitely.  Ordinary 
vaselin  does  not  long  remain  sterile  when  exposed,  and,  like  all  oily 
substances,  it  is  injurious  to  soft-rubber  and  webbing  catheters  and  is 
difl&cult  to  clean  off.  The  excess  of  the  lubricant  should  be  wiped  ofif 
on  the  meatus,  so  as  to  insure  that  none  be  carried  into  the  bladder. 

CYSTITIS 

Unless  scrupulous  care  is  exercised  in  employing  the  catheter — • 
and  sometimes  apparently  in  spite  of  scrupulous  care — a  troublesome 
cystitis  is  likely  to  be  set  up  which  may  last  for  many  weeks.  It  does 
not  appear  ordinarily  until  a  week  or  more  has  passed  from  the  time 
the  use  of  the  catheter  was  begun. 

Cystitis  following  catheterization  of  the  normal  urethra  is  due  to  the 
introduction  of  infective  matter  into  the  bladder.  Any  pyogenic  bac- 
terium may  cause  it — most  frequently  the  colon  bacillus,  next  the 
staphylococcus  or  streptococcus.  The  gonococcus  apparently  acts  to 
pave  the  way  for  invasion  by  some  other  organism,  as  it  is  usually 
found  associated  with  one  of  .those  already  mentioned.  The  catheter 
may  be  clean  and  yet  carry  infection  into  the  bladder,  for  the  healthy 
urethra  is  the  normal  habitat  of  several  species  of  bacteria  which  are 
capable  of  producing  cystitis. 

A  frequent  source  of  cystitis  is  by  contagion  from  contiguous  organs. 
In  the  female  particularly,  as  catheterization  is  commonly  practised,  it 
is  extremely  likely  for  the  catheter  or  the  fingers  of  the  nurse  to  be  con- 
taminated by  organisms  from  the  rectum  or  vagina.  Cystitis  is  especi- 
ally likely  to  occur  where  retention  of  urine  exists.  In  the  female 
susceptibility  seems  to  be  increased  during  menstruation  or  the  puer- 
perium. 

The  earliest  symptoms  of  acute  cystitis  are  increased  frequency 
and  urgency  of  micturition,  and  pain.     The  patient  feels  compelled  to 


CYSTITIS  137 

urinate  immediately  the  desire  arises,  and  the  expulsion  of  the  last  few 
drops  is  accompanied  by  sharp,  scalding  pain.  The  irritable  condi- 
tion of  the  vesical  sphincters  and  of  the  urethra  may  cause  the  passage 
of  urine  every  few  moments.  Sometimes,  on  account  of  pain  attending 
the  passage  of  urine,  there  is  retention.  There  is  usually  a  continued 
low-grade  fever,  and  the  patient  is  restless  and  sleepless  and  loses  his 
appetite.  The  urine  is  cloudy  and  contains  pus  and  may  contain  blood.  '^ 
In  acute  cases  the  urine  may  be  strongly  acid  or  alkaline,  depending 
upon  the  responsible  organism.  In  the  presence  of  the  colon  bacillus 
the  urine  is  acid. 

Sometimes  the  condition  of  irritable  bladder  will  resemble  cystitis 
so  closely  as  to  be  confounded  with  it.  This  not  infrequently  arises 
in  any  condition  attended  by  a  highly  concentrated  urine,  such  as  usually 
occurs  just  after  anesthetization.  The  symptoms  are  probably  induced 
by  the  hyperemia  of  the  bladder  w^all  which  results  from  irritation  by 
such  a  urine.  The  indication  in  this  event  is  to  increase  the  amount 
of  body  fluids  by  copious  drinking,  instillation  of  water  by  rectum  or 
subcutaneous  infusion,  with,  if  necessary,  the  exhibition  of  such  drugs 
as  potassium  citrate,  or  acetate,  or  digitalis. 

The  treatment  of  postoperative  acute  cystitis  may  be  considered 
under  the  following  heads :  prophylactic,  medicinal,  local,  and  operative. 

Prophylactic. — The  importance  of  asepsis  in  all  the  details  of  cathe- 
terization needs  no  further  emphasis.  If  an  acute  gonorrhea  exists, 
a  catheter  should  not  be  used,  even  if  the  only  alternative  is  suprapubic 
puncture  of  the  bladder.  The  danger  of  passing  a  catheter  under  a 
sheet,  with  its  impossibility  of  asepsis  and  its  danger  of  traumatism 
to  the  urethra,  has  already  been  dwelt  upon.  The  internal  use  of 
urotropin  (hexamethylamin)  before  catheterization,  to  inhibit  the  growth 
of  pyogenic  organisms  in  the  urine,  is  sometimes  advocated. 

General  and  Medicinal. — In  order  to  avoid  tenesmus  the  patient 
should  be  kept  quiet  upon  his  back  in  bed  until  the  acute  symptoms 
have  mitigated  somewhat.  Ordinarily,  patients  find  it  comfortable  to 
draw  up  the  knees,  as  this  relaxes  the  abdominal  muscles  and  so  dimin- 
ishes pressure  upon  the  bladder.  The  use  of  hot  applications  will 
usually  be  found  efficient  in  relieving  pain — hot  suprapubic  applica- 
tions should  be  applied  several  times  daily,  stupes  or  fomentations 
should  be  applied  to  the  perineum,  hot  water  may  be  run  through  a 
rectal  siphon  plug,  or,  if  the  patient  can  be  moved,  he  can  be  placed 
in  a  hot  sitz-bath.  If  tenesmus  exists,  morphin  should  be  given  in 
moderation.  It  acts  most  efficiently  if  given  in  the  form  of  a  sup- 
pository, with  extract  of  belladonna,  of  each,  {  gr.     For  intense  tenesmus 


138  catheterization;  cystitis;  catheter  fever 

the  instillation  of  10  minims  of  a  20  per  cent,  solution  of  cocain  into 
the  deep  urethra  by  means  of  a  Keyes-Ultzmann  syringe  should  be  tried. 
Anything  which  decreases  the  pain  or  tenesmus  and  helps  to  quiet  the 
bladder  in  so  far  assists  the  cure. 

Internally,  the  administration  of  urinary  antiseptics  is  indicated,  to 
render  the  urine  bland  and  unirritating,  and  inhibit,  as  far  as  possible,  the 
■growth  of  the  bacteria  in  the  bladder.  Urotropin  (hexamethylamin, 
cystogen,  helmitol)  may  be  given  in  the  dose  of  5  or  7J  gr.  every  four 
hours  for  some  days.  As  this  group  of  drugs,  whose  activity  depends 
upon  the  generation  of  formaldehyd,  tend  to  irritate  the  kidneys,  their 
use  should  not  be  maintained  constantly  for  too  long  a  time.  If  much 
water  is  being  drunk,  the  drug  is  diluted  and  its  irritating  action  is  de- 
creased. Salol  is  efiScient  in  doses  of  10  gr.  If  the  urine  is  strongly 
acid,  alkahs,  such  as  bicarbonate  of  soda  in  20-gr.  doses,  or  potassium 
citrate  or  acetate,  in  doses  of  10  or  15  gr.,  should  be  given.  An  ac- 
ceptable method  of  administering  these  drugs  is  in  lemonade,  a  pitcher 
to  be  kept  constantly  by  the  bedside  containing  the  proper  amount. 
If  the  urine  is  alkaline,  its  reaction  may  be  modified  by  the  administra- 
tion of  acids.  Sodium  benzoate  should  be  given  in  7-  or  lo-gr.  doses 
every  four  hours  in  a  glass  of  water.  Benzoic  acid  is  also  useful  in  10- 
to  15-gr.  doses;  it  is  given  dissolved  in  water,  with  borax  or  sodium 
phosphate  added  to  increase  its  solubility  and  cinnamon-water  added 
to  flavor. 

The  concentration  of  the  urine  should  be  combated  by  copious 
drinking  of  water.  To  avoid  disturbance  of  rest  during  the  night  by 
the  necessity  for  urination,  the  drinking  should  be  confined  largely  to 
the  morning  and  early  afternoon.  Ordinary  water,  bottled  waters, 
carbonated  or  still,  albumin-  and  barley-water,  and  toast-water  may  be 
given,  but  all  stimulating  and  fermented  beverages,  tea  and  coffee, 
must  be  avoided.  The  diet  should  be  simple  and  light,  and  in  the 
early  stages  of  a  severe  acute  cystitis  should  be  limited  to  milk.  Rich 
and  highly  spiced  or  seasoned  foods  should  not  be  allowed — particularly 
meats,  fish,  and  salads.  The  bowels  should  be  kept  active  by  means 
of  mild  laxatives;   purgatives  and  drastic  cathartics  should  be  avoided. 

In  cases  of  chronic  cystitis,  where  the  colon  bacillus  is  demonstrable 
in  the  urine,  the  use  of  an  autogenous  vaccine  is  to  be  recommended. 
For  the  technique  of  its  production  and  administration,  see  Chapter 
LII. 

Local. — Ordinarily  in  acute  cystitis  irrigation  of  the  bladder  is  not 
indicated,  and  as  a  routine  measure  should  not  be  employed.  If,  how- 
ever, the  condition  should  fail  to  clear  up  under  the  regime  just  pre- 


CYSTITIS  139 

scribed,  or  if  the  urine  becomes  foul  and  shows  the  presence  of  de- 
composing pus,  intravesical  irrigation  is  necessary.  The  washing 
should  be  begun  with  normal  salt  solution  or  the  mildest  of  antiseptics, 
such  as  2  or  4  per  cent,  boric  acid  solution.  In  the  acute  stage  astrin- 
gents and  strong  antiseptics  should  not  be  employed.  If  the  condition 
does  not  improve  under  the  boric  acid  irrigation,  it  will  become  necessary 
gradually  to  work  up  to  the  stronger  antiseptics.  Argyrol  may  be  used 
in  I  :  1000  solution;  silver  nitrate,  i  :  5000,  gradually  increasing  to 
I  :  500;  potassium  permanganate,  i  :  5000,  gradually  increasing  to 
I  :  1000;  or  carbolic  acid,  i  :  1000.  Of  these,  the  most  commonly 
employed  is  silver  nitrate;  when  pain  follows  its  use,  it  must  be  aban- 
doned. 

Irrigations  should  be  practised  every  other  day,  daily,  or  twice  a 
day,  depending  on  the  urgency  of  the  case  and  the  character  of  the 
urine.  All  fluids  must  be  distinctly  warm  at  the  time  they  enter  the 
bladder.  The  urine  is  passed  or  withdrawn  before  the  washing  is 
begun,  and  the  irrigation  is  maintained  until  the  wash-water  returns 
clean.  The  hydrostatic  pressure  obtained  by  hanging  the  bag  so  that 
its  contents  are  2  or,  at  most,  3  feet  above  the  level  of  the  bladder 
is  sufficient.  In  order  to  avoid  instrumentation  it  is  preferable  to 
irrigate  without  the  use  of  the  catheter.  A  patient  with  a  little  effort 
can  learn  to  relax  his  abdominal  muscles,  and  the  pressure  of  the  fluid 
will  overcome  the  natural  resistance  of  the  sphincters;  6  or  8  ounces 
may  ordinarily  be  introduced,  when  the  irrigating  tip  is  removed 
from  the  urethra  or  the  catheter  and  the  fluid  are  allowed  to  come  away. 
As  soon  as  the  patient  announces  a  feeling  of  discomfort,  the  introduc- 
tion should  cease.  As  the  natural  tendency  is  for  the  bladder  to  con- 
tract in  cystitis,  sometimes  the  amount  of  fluid  which  can  be  retained 
is  small.  It  is  good  practice  to  leave  in  an  ounce  or  so  of  the  irrigating 
fluid,  or  to  inject  an  ounce  of  5  to  10  per  cent,  argyrol  solution,  to  remain 
until  the  next  urination. 

Operative. — In  subacute  or  chronic  cystitis  permanent  drainage 
sometimes  becomes  necessary.  A  catheter  a  demeure,  or  an  ordinary 
soft-rubber  catheter  held  in  by  adhesive  plaster,  will  give  rest  to  a  con- 
tracted bladder  and  will  allow  for  frequent  irrigations.  Sometimes  in 
the  male  it  is  necessary  to  afford  drainage  by  means  of  a  suprapubic 
cystotomy  or  a  perineal  urethrotomy,  and  in  the  female  by  dilatation 
of  the  urethra  and  suprapubic  or  vaginal  cystotomy.  Curettage  of  the 
bladder  is  rarely  indicated. 

(For  the  after-treatment  of  these  operations,  see  Part  II,  under 
special  headings.) 


I40  catheterization;  cystitis;  catheter  fever 

CATHETER  FEVER 

It  was  observed  for  many  years  that  instrumentation  of  the  male 
urethra  was  not  infrequently  followed  by  an  amount  of  constitutional 
disturbance.  This  was  given  variously  the  name  of  catheter  chill, 
catheter  fever,  urinary  fever,  etc.,  but  was  never  carefully  studied  until 
Thorndike^  analyzed  the  condition  and  classified  four  forms,  which  he 
called  urethral  shock,  acute  urinary  fever,  chronic  urinary  fever,  and 
septic  infection. 

Urethral  shock,  frequently  called  catheter  chill,  is  a  condition  of 
nervous  shock  ordinarily  manifested  by  the  occurrence  of  a  chill  with- 
out fever  directly  or  very  shortly  after  instrumentation.  This  condi- 
tion is  common  and  may  follow  the  simple  passage  of  an  instrument  in 
a  normal  urethra.  It  is  especially  apt  to  follow  the  patient's  first  in- 
strumentation— that  is,  if  a  patient  does  not  exhibit  these  symptoms 
after  his  first  instrumentation  it  is  unlikely  to  follow  repetitions  of  the 
instrumentation.  Patients  who  have  had  chills  are  likely  to  have  more. 
It  is  sometimes  speedily  fatal.  The  patient  becomes  faint  and  may 
completely  lose  consciousness.  The  chill  is  short  and  sharp,  is  of  a  few 
moments'  duration,  and,  if  not  fatal,  is  followed  by  little  if  any  con- 
stitutional disturbance. 

Acute  urinary  fever,  sometimes  called  catheter  fever,  comes  on  usually 
several  hours  after  the  instrumentation  and  generally  shortly  after  the 
first  urination  following  the  passage  of  the  instrument.  The  patient 
experiences  a  distinct  chill.  He  looks  badly,  takes  on  an  uncomfortable 
expression,  and  complains  of  pains  in  his  head  and  back.  The  tem- 
perature rises  sometimes  as  high  as  io8°F.,  and  there  maybe  vomiting. 
The  fever  lasts  a  few  hours  and  is  followed  by  exhaustion  and  perspira- 
tion. After  twenty-four  hours  the  patient  has  recovered  his  former 
condition.  This  complication  will  also  follow  operations  upon  the 
urethra,  such  as  internal  urethrotomy,  particularly  where  there  is  con- 
tact of  urine  with  the  operated  surface.  It  is  probable  that  these  febrile 
attacks  are  due  to  poisonous  material  of  some  sort,  either  chemical  or 
bacterial,  furnished  by  the  urine  and  absorbed  through  the  wound 
made  by  the  operation,  or  through  the  mucous  membrane  of  the  urethra, 
which  has  been  stretched  and  possibly  torn  by  the  instrumentation. 

Chronic  urinary  fever  comes  on  after  catheterization  in  cases  where 
destructive  disease  has  preexisted  in  some  form  for  a  long  time  and  is 
particularly  likely  to  follow  the  passage  of  a  catheter  for  the  relief  of 

^  Paul  Thorndike,  Disturbances  "Which  May  Follow  Instrumentation  upon  the  Male 
Urethra  and  Bladder,  Com.  Mass.  Med.  Soc,  1892,  v,  401;  see  also  L.  J.  Hammond, 
Catheter  Fever,  Ann.  Surg.,  1909,  xlix,  90. 


CATHETER    FEVER  I4I 

a  more  or  less  distended  and  atonied  bladder.  The  catheter  is  passed 
and  the  residual  urine  is  drawn  off.  A  few  days  later  the  patient  ex- 
periences chilly  sensations  and  becomes  feverish.  He  loses  his  appetite, 
suffers  from  thirst,  and  feels  wretched.  Evidences  of  a  cystitis  are  present. 
This  condition  may  persist  for  weeks  and  yet  the  patient  recover. 
On  the  other  hand,  he  may  die.  In  the  fatal  cases  autopsy  shows  ad- 
vanced ascending  disease  of  ureter  and  kidney,  such  as  dilated  ureter, 
contracted  bladder,  hydronephrosis  and  pyonephrosis.  Two  conditions 
are  essential  to  bring  about  this  condition :  one  is  a  preexisting  degen- 
eration of  the  secretory  substance  of  the  kidney;  second,  an  alteration, 
from  obstruction,  in  the  intrarenal  pressure,  whereby  the  ureters,  pelves, 
and  calices  of  the  kidneys  become  dilated.  The  sudden  release  of  the 
increased  pressure  caused  by  long-standing  urethral  obstruction  of  some 
sort  starts  up  a  state  of  active  congestion  in  the  kidney. 

Septic  infection  from  an  unclean  instrument  may  cause  merely  a 
mild  cystitis.  The  cystitis  may  be  severe  and  extend  upward  and  cause 
septic  trouble  in  the  kidney,  or  it  may  manifest  itself  as  a  true  general 
septicemia  or  pyemia. 

The  treatment  of  these  manifestations  is  a  matter  of  intense  im- 
portance to  any  surgeon  who  may  be  brought  in  contact  with  operative 
geni to-urinary  work.  Much  more  can  be  done  in  the  way  of  prophylaxis 
to  prevent  such  complications  from  arising  than  in  the  way  of  treatment 
once  they  have  arisen. 

Urethral  shock  appears  to  be  independent  of  absorption,  because 
it  shows  itself  immediately  after  the  instrumentation  and  before  sufficient 
time  has  elapsed  for  the  effects  of  bacterial  absorption  to  make  them- 
selves evident.  The  condition  is  apparently  in  the  nature  of  an  over- 
powering impression  upon  a  susceptible  nervous  system.  Fear,  anxiety, 
and  pain  are  strong  contributing  factors  in  the  production  of  urethral 
shock,  and  if  the  patient  is  overwrought  and  apprehensive,  so  that  shock 
in  connection  with  urethral  instrumentation  is  a  probability,  anticipatory 
measures  must  be  taken.  Freedom  from  pain  and  anxiety  may  be 
insured  by  the  ample  use  of  local  and  general  sedatives  and  morphin, 
and  the  instillation  of  cocain  through  the  Keyes-Ultzman  syringe  should 
always  be  employed  preceding  the  first  instrumentation  in  a  nervous 
patient  and  before  instrumentation  in  those  who  have  had  urethral 
shock  before.  The  gradual  education  of  the  patient  and  urethra  to 
the  point  of  tolerance  of  instrumentation  is  an  element  in  prophylaxis 
of  no  mean  value.  With  the  condition  once  established,  the  hypodermic 
use  of  morphin  is  indicated. 

In  the  other  forms  absorption  of  bacteria  and  their  products  is  the 


142  catheterization;  cystitis;  catheter  fever 

essential  element,  which  must  be  attacked  both  for  prophylaxis  and 
relief.     The  importance  of  surgical  asepsis  need  only  be  mentioned. 

Absorption  may  be  prevented,  first,  by  neutralizing  the  injurious 
elements  before  their  absorption,  that  is,  by  internal  antisepsis;  second, 
by  washing  them  out  of  an  involved  urethra  before  or  after  instrumenta- 
tion; and,  third,  by  securing  complete  and  effective  drainage  of  the 
urethra.  Internal  antisepsis  is  furthered  by  the  administration  of  uro- 
tropin,  salol,  and  the  other  urinary  antiseptics  already  mentioned. 
Digitalis  is  strongly  supportive  and  stimulating  to  the  renal  secretion. 
Local  antisepsis  and  asepsis  are  best  secured  by  copious  and  frequently 
repeated  irrigations  of  the  urethrovesical  tract  with  a  solution  of  nitrate 
of  silver,  argyrol,  boric  acid,  or  potassium  permanganate.  It  should 
be  the  rule  to  precede  all  instrumentation  (such  as  the  use  of  sounds 
after  a  urethrotomy)  by  the  administration  of  hexamethylamin  and 
to  follow  it  by  a  urethral  irrigation.  With  these  precautions  ordinary 
soundings  need  not  be  feared. 

As  a  result  of  recent  experience  it  has  been  amply  demonstrated  that 
extensive  urethral  manipulation  may  be  carried  on  with  impunity  if  co- 
incidentally  free  and  constant  drainage  of  the  bladder  is  provided.  Thus, 
it  has  come  to  be  the  practice  of  conservative  surgeons,  especially  in 
doubtful  cases,  to  add  external  urethrotomy  to  operations  for  stricture, 
and  perineal,  drainage  in  operations  upon  the  prostate  and  bladder. 
Under  these  circumstances  urethral  fever,  which  was  formerly  the  bug- 
bear of  geni to-urinary  surgery,  is  now  rarely  observed.  In  case  this 
rule  is  not  for  any  reason  followed,  a  large  calibered  soft-rubber  catheter 
should  be  tied  in  through  the  urethra  for  several  days,  or  the  urethra 
should  be  kept  clean  by  frequent  irrigations. 

When  urinary  fever  intervenes,  in  chronic  or  debilitated  cases,  the 
best  method  of  maintaining  bladder  drainage  is  by  means  of  a  large 
double  rubber  drainage-tube  or  two  soft-rubber  catheters  sewed  back 
to  back  with  silk,  introduced  through  a  perineal  incision.  In  urgent 
cases  a  constant  stream  of  warm  sterile  saline  or  boric  acid  solution 
may  be  maintained  under  low  pressure  through  one  tube,  with  the  out- 
let by  means  of  siphonage  through  the  other. 


CHAPTER  XV 

CARE  OF    THE  BOWELS:  CATHARTICS,    ENEMAS, 
DISTENTION,  FOMENTATIONS 

In  normal  active  adults  nature  makes  ample  provision  for  the  regular 
evacuation  of  the  intestinal  residue.  Peristalsis  is  excited  reflexly  and 
mechanically  by  the  presence  of  food  in  the  gastro-intestinal  tract; 
mechanically,  by  coarse  foods,  rich  in  fiber  and  cellulose,  and  indigest- 
ible elements  such  as  bran,  seeds,  and  the  skin  of  fruit.  The  presence 
of  food  in  the  stomach  not  only  induces  activity  in  the  intestines,  but 
stimulates  also  the  colon  and  rectum  to  motion,  provided  a  sufficient 
quantity  of  material  has  been  collected  in  them.  Bile  is  also  an  im- 
portant element  in  natural  purgation  in  a  way  not  yet  clearly  under- 
stood, for  obstinate  constipation  is  frequently  observed  if  the  biliary 
secretion  is  prevented  from  reaching  the  intestines,  and  some  of  the 
drastic  purgatives,  such  as  rhubarb  and  podophyllin,  fail  to  act  in  its 
absence.  This  biliary  secretion  is  provided  for  by  the  massaging,  so 
to  speak,  which  the  liver,  gall-bladder,  and  its  ducts  receive  during 
exercise,  such  as  walking.  Thus,  in  active  persons  nature  provides 
mechanical  and  chemical  stimuli  to  evacuation  which,  provided  the 
fecal  content  of  the  intestines  is  not  allowed  to  become  hard  from  in- 
sufiiciency  of  water,  should  sufiice.  To  these  may  be  added  the  psycho- 
logic stimulus  of  regular  habit,  such  as  having  a  movement  of  the  bowels 
daily  after  breakfast,  which  is  important  but  valueless  after  it  has  once 
been  broken,  for  it  has  to  be  re-formed. 

When  a  person,  for  one  cause  or  another,  is  obliged  to  give  up  active 
life  and  keep  his  bed,  all  these  agents  are  interfered  with  in  their 
functioning — he  is  deprived  of  the  beneficial  effects  of  ordinary  exercise, 
his  habit  is  broken  by  the  unaccustomed  circumstances  in  which  he 
finds  himself,  his  diet  is  freed  in  great  part  from  the  coarser  elements 
which  exert  a  salutary  influence  in  exciting  peristalsis.  In  addition  to 
these  considerations  is  the  purely. mechanical  one  of  position — the  habit 
of  defecation  in  the  supine  posture  is  sometimes  difficult  to  acquire.  As 
a  result  a  patient  may  be  allowed  to  become  constipated,  partly  from 
oversight  on  the  side  of  the  surgeon,  partly  from  lack  of  energy  and  of 
desire  on  the  side  of  the  patient,  and  it  is  not  infrequent  that  the  fecal 

143 


144  CARE    OF   THE   BOWELS 

content  becomes  packed  so  hard  and  so  tight  in  the  rectum  as  to  require 
digital  or  instrumental  removal.  Constipated  patients  often  develop 
anorexia  and  complain  of  headache  and  a  feeling  of  weight  in  the  lower 
abdomen,  all  of  which  may  interfere  with  progress  toward  recovery. 
Frequently  hemorrhoids  develop,  or,  if  already  present,  become  aggra- 
vated and  complicate  treatment  of  the  constipation. 

In  any  given  case  the  natural  conditions  under  which  the  patient 
has  lived  should  be  approximated  as  closely  as  possible.  If  there  is 
no  contra-indication,  the  abdomen  should  be  massaged  for  a  few  minutes 
morning  and  night,  a  trick  which  any  competent  nurse  can  be  taught  by 
one  demonstration.  The  food  should  as  closely  simulate  that  to  which 
the  patient  is  accustomed  as  his  condition  will  permit.  There  should 
be  plenty  of  fluids  and  liquid  foods,  and  farinaceous  foods,  jellies,  jams, 
and  marmalade,  fruits,  raw  or  stewed,  prunes  or  figs.  The  patient 
should  understand  that  he  is  to  be  expected  to  defecate  at  about  a  cer- 
tain hour  every  morning.  If  it  can  be  allowed,  the  patient  should  be 
permitted  to  get  out  of  bed,  with  assistance,  and  move  his  bowels  sitting 
upon  a  closet  or  stool;  and,  finally,  the  responsibilit}'  over  the  state  of 
the  bowels  should  never  be  left  with  the  nurse  or  attendant;  the  surgeon, 
ignoring  any  sense  of  false  modesty  on  his  part  or  the  part  of  the  patient, 
should  acquire  the  habit  of  automatically  asking  the  patient  directly, 
at  the  time  of  his  morning  visit,  whether  or  not  the  bowels  have  moved 
during  the  past  twenty-four  hours. 

It  may  be  taken  as  a  general  rule  that  patients  who  are  kept  on  their 
backs  for  weeks  or  months  will  require  at  some  time  medication  of  a  sort 
to  assist  in  maintaining  intestinal  activity.  Whether  the  bowels  should 
be  moved  daily  or  every  other  day  depends  partly  on  the  patient.  Some 
persons  who  have  been  accustomed  to  evacuate  their  bowels  daily,  or 
even  twdce  a  day,  may  develop  considerable  physical  discomfort,  along  with 
mental  irritability  and  inability  to  sleep,  if  they  are  obliged  to  go  forty- 
eight  hours  without  a  movement.  Others,  of  a  more  or  less  constipated 
habit,  may  go  for  some  days  or  a  week  before  they  will  call  the  atten- 
tion of  the  doctor  to  the  state  of  things.  If  a  movement  of  the  bowels 
be  attended  with  discomfort  or  inconvenience,  as,  for  instance,  in  a  case 
of  wired  fracture  of  the  hip,  with  more  or  less  cumbersome  apparatus, 
the  rule  should  be  a  movement  every  other  day.  In  other  cases  the 
surgeon  will  be  governed  by  conditions,  never,  under  ordinary  circum- 
stances, allowing  the  intestinal  residue  of  a  person  on  a  fairly  free  diet 
to  accumulate  more  than  forty-eight  hours. 


CATHARTICS  I45 

CATHARTICS 

A  simple  and  not  unpleasant  measure  to  assist  in  moving  the 
bowels  is  the  employment  of  one  or  another  of  the  numerous 
bottled  laxative  waters — natural  or  artificial;  a  wineglassful  taken 
slowly  before  breakfast  is  usually  just  sufficient  to  prevent  the  fecal 
mass  from  becoming  hard  and  dry  and  difficult  to  move  onward;  or  a 
tablespoonful  of  olive  oil,  taken  with  each  meal,  may  be  just  sufficient, 
by  mechanically  lubricating  and  preventing  the  intestinal  content  from 
becoming  dry  and  impacted,  to  allow  of  one  gentle  movement  daily. 
A  small  dose  of  castor  oil,  one-half  or  one  teaspoonful,  taken  every 
morning,  will  often  keep  the  bowels  in  excellent  condition  where  other 
and  more  irritating  drugs  may  fail.  It  can  be  used  freely,  because  it 
is  safe  and  has  no  bad  effects.  It  may  be  agreeably  taken  in  beer  or 
tea,  according  to  the  taste  of  the  patient.  A  pleasant  way  of  serving 
it,  so  that  the  patient  does  not  taste  it  at  aU,  is  to  wet  the  inside  of  a 
wineglass,  pour  in  a  little  water  or  peppermint  water,  float  on  top  of 
this  the  castor  oil,  and  then  pour  in  a  little  brandy,  which,  being  lighter 
than  the  oil,  w^ill  cover  it,  forming  a  sort  of  ''sandwich,"  which  should 
be  drunk  at  one  gulp.  A  teaspoonful  of  the  compound  licorice  powder, 
more  or  less,  may  be  taken  at  night,  stirred  up  in  a  little  water;  or  cascara, 
the  extract,  in  the  form  of  pills,  or,  better,  as  the  fluidextract,  which  may 
be  made  to  taste  more  pleasant  by  the  addition  of  aromatics.  Some 
patients  prefer  the  officinal  A.  S.  and  B.  or  the  compound  cathartic  pill. 
Phenolphthalein,^  in  one  or  another  of  its  proprietary  forms,  is  agreeable 
to  take  and  works,  as  a  rule,  gently  and  pleasantly  in  small  doses.  There 
is  a  considerable  advantage  in  the  occasional  use  of  laxatives,  in  that 
it  prevents  straining  at  stool,  with  the  uncomfortable  effects  this  may 
have  on  hemorrhoids  or  hernia.  Moreover,  straining  is  attended  by 
a  considerable  increase  in  intra-abdominal  pressure,  which,  by  causing 
a  congestion  in  the  vessels  of  the  brain,  may  be  sufficient  to  determine 
an  apoplexy  in  elderly  persons,  or  it  may  be  the  exciting  cause  in  the 
setting  free  of  an  embolus. 

If  the  bowels  require  stimulation  stronger  than  that  given  by 
the  laxative  measures  detailed  above,  it  will  become  necessary  to  give 
these  drugs  in  larger  doses  or  to  employ  purgatives.     These  range  from 

^  Berthoumeau  and  Daguin  (Purgative  Properties  of  Phenolphthalein,  Prcsse  Medicale, 
Paris,  1908,  xvi,  378)  re\'iew  the  literature  on  this  comparatively  new  agent  and  rei)ort  ex- 
tensive personal  experimental  research.  The  results  show  that  phenolphthalein  increases, 
on  direct  contact,  the  contracting  power  and  the  secretion  of  the  intestines.  Beyond  this 
action  on  the  intestines  the  drug  does  not  seem  to  induce  any  noticeable  modification  in  the 
other  functions.  In  the  dose  of  from  0.5  to  0.8  gm.  (yi  to  12  gr.)  it  purges  without  griping. 
The  laxative  dose  is  4  or  5  gr.  or  less. 
10 


146  CARE    OF   THE   BOWELS 

Epsom  salt  and  calomel  to  the  drastic  croton  oil  or  elaterin.  Calomel 
in  small  doses  gives  soft  stools,  generally  without  pain  or  straining, 
apparently  through  acting  as  an  intestinal  irritant.  Calomel  has  this 
peculiarity,  that  its  cathartic  action  is  not  increased  in  direct  propor- 
tion to  the  dose,  for  calomel  itself  is  insoluble,  only  the  portion  which 
is  changed  to  the  gray  oxid  is  active,  and  the  major  part  of  the  large 
dose  is  thrown  out  unchanged  in  the  stool,  and  for  this  reason  the  best 
effect  is  obtained  by  administering  small  doses  (from  y^  to  -|-  gr.)  at 
half-hour  intervals  until  a  movement  results.  It  is  tasteless,  and  is  not, 
as  a  rule,  rejected  by  the  stomach  even  when  there  is  vomiting.  If  it 
fails  to  act,  it  should  be  followed  by  a  Seidlitz  powder,  Epsom  salt,  or  an 
enema.  The  salines  commonly  employed  are  magnesium  sulphate^ 
(Epsom  salt),  magnesium  citrate  (effervescent),  and  the  double  tartrate 
of  sodium  and  potassium  (Rochelle  salt,  usually  administered  as  pulvis 
effervescens  compositus  or  Seidlitz  powder) .  These  act,  not  by  irritating 
the  intestine,  but,  having  a  higher  osmotic  pressure  than  the  blood,  by 
inducing  a  secretion  of  fluids  from  the  intestinal  wall,  until  the  weight  of 
this,  added  to  its  own  weight  and  bulk  (being  itself  practically  insolu- 
ble), induces  increased  peristalsis  and  the  whole  is  evacuated.  AU 
these  must  be  given  in  solution;   if,  however,  the  solution  is  weak,  or  if 

^  W.  F.  Boos  (Magnesium  Poisoning,  Boston  Med.  and  Surg.  Jour.,  July  22,  1909, 
clxi,  122)  has  shown  that  magnesium  poisoning  is  probably  more  frequent  than  is  generally 
supposed,  the  true  cause  of  the  toxic  condition  remaining  unknown  in  most  cases.  Two 
of  the  three  cases  which  the  author  had  the  opportunity  to  study  were  brought  to  his  notice 
merely  through  the  high  specific  gravity  of  the  urine.  In  one  case  the  specific  gravity 
of  the  specimen  obtained  was  1070  and  in  the  other  loSo.  These  two  cases  recovered, 
while  the  third  case  ended  fatally.  Fraser  reports  a  case  of  his  own,  and  discusses  6  others 
which  he  found  in  the  literature.  Five  of  these  6  cases  ended  fatally.  In  the  author's 
3  cases  the  intoxication  was  undoubtedly  caused  by  the  absorption  of  large  quantities  of 
magnesium  sulphate  from  the  gastro-intestinal  tract. 

The  author  has  made  a  careful  study  of  the  10  cases  now  available,  and,  in  addition, 
has  carried  out  certain  experimental  work  on  the  conditions  which  govern  the  absorption 
of  Epsom  salt  solutions.  He  finds  that  in  the  absence  of  hydremia  the  tendency  of  mag- 
nesium sulphate  to  be  absorbed  increases  with  the  concentration  of  the  solution,  the  dry 
salt  being  completely  absorbed  without  action  on  the  bowels.  This  fact  was  shown  by 
Hay  to  be  true  also  of  Glauber  salt.  In  hydremic  conditions,  however,  the  salt,  even  when 
it  is  given  in  very  concentrated  solution,  is  not  absorbed.  It  appears,  therefore,  that  the 
practice  of  giving  very  concentrated  solutions  of  magnesium  sulphate  to  deplete  the  sys- 
tem of  excessive  water  is  rational,  but  perhaps  not  without  possible  danger. 

In  the  absence  of  edema  or  ascites,  the  object  of  giving  magnesium  sulphate  can  be  none 
other  than  to  produce  efficient  catharsis.  To  attain  this  object  without  incurring  the 
danger  of  intoxication  from  absorption  the  salt  is  best  given  in  solutions  not  exceeding 
6  per  cent,  in  concentration.  Above  this  concentration  more  or  less  magnesium  sulphate 
is  absorbed  and  is  lost  to  catharsis,  while  its  presence  in  the  circulation  is  a  menace  to  the 
patient's  life.  In  the  wards  of  the  Massachusetts  General  Hospital  the  patients  are  now 
given  ^  oz.  of  Epsom  salt  dissolved  in  3  oz.  of  water,  to  be  followed  immediately  by  a  glass 
of  water  (6  oz.) ;  this  represents  approximately  a  6  per  cent,  solution. 


CATHARTICS  I47 

the  blood  and  tissues  are  impoverished  of  fluid,  evacuation  is  less 
likely  to  occur.  As  they  act  rapidly,  they  are  best  given  in  the  morning. 
Many  persons  are  nauseated  by  Epsom  salt,  and  especially  after  ether 
is  vomiting  likely  to  occur;  in  either  case  the  salt  should  be  given  cold 
and  dilute.  Croton  oil  may  be  given  in  doses  of  ^  to  2  minims  on 
a  crumb  of  bread,  on  a  lump  of  sugar,  or  mixed  with  butter  or  olive 
oil.  It  is  a  powerful  irritant,  and  in  any  but  small  doses  acts  as  a 
poison.  It  acts  effectually  and  without  causing  much  pain  or  incon- 
venience after  other  drugs  have  failed.  Elaterin  is  a  powerful  hydra- 
gogue  cathartic  which  acts  rapidly  by  irritation.  It  is  given  in  the 
form  of  the  officinal  trituration  of  elaterin,  in  the  dose  of  ^  gr.  The 
disadvantage  of  employing  the  more  powerful  drugs  is  that  their  action 
is  always  unpleasant  to  the  patient  and  the  evacuations  are  loose.  Often- 
times the  action  of  the  drug  may  be  continued  over  an  hour  or  more, 
so  that  the  patient  is  annoyed  and  distressed  and  may  be  considerably 
weakened  by  frequent  watery  movements  of  scanty  amount. 

It  is  not  always  necessary  to  excite  peristalsis  of  the  small  intestine 
by  means  of  drugs  in  order  to  clear  out  the  bowel,  because  not  infre- 
quently the  want  of  activity  depends,  not  upon  the  small  intestine,  but 
upon  the  rectum,  which,  by  training  or  habit,  has  become  so  accus- 
tomed to  the  pressure  of  fecal  matter  that  it  no  longer  irritates  to  the 
extent  of  setting  up  a  reflex  desire  for  defecation.  In  other  cases,  there 
is  a  distinct  disadvantage  in  exciting  intestinal  activity.  In  either 
event  we  resort  to  the  use  of  local  measures — enemas  or  suppositories. 
One  of  the  best  means  of  ridding  the  rectum  of  accumulated  feces  is  the 
employment  of  glycerin.  This  works  immediately  when  it  works  at  all. 
The  stool  which  results  is  of  ordinary  consistency;  there  is  but  one 
movement,  and  that  is  unaccompanied  by  pain  or  colic.  Its  action 
depends  largely  upon  its  lubricating  quality,  partly  upon  its  ability 
to  excite  a  watery  secretion  from  the  mucous  membrane  with  which 
it  comes  in  contact,  and  chiefly  by  providing,  through  its  irritant  action, 
the  reflex  stimulus  which  was  lacking.  The  glycerin  should  be  in- 
jected low  into  the  rectum,  in  a  dose  of  -|  to  2  teaspoonfuls.  .  The  more 
convenient  mode  of  administration  is  in  the  form  of  suppositories,  the 
officinal  suppository  being  made  up  of  45  gr.  of  glycerin  gelatinized  by 
means  of  soap.  These  weaken  with  age  as  the  glycerin  tends  to  escape. 
An  almost  equally  efficacious  suppository  is  that  made  by  whittling  out 
a  piece  of  Castile  soap  to  shape.  This  should  be  moistened  before  intro- 
duction. 

Digital  Bvacuation  of  Rectum. — If  it  becomes  evident  that 
there  is  impaction  in  the  rectum  to  such  an  extent  that  these  measures 


148  CARE    OF    THE    BOWELS 

are  inefficient,  or  result  only  in  painful  watery  evacuations,  it  will  be 
necessary  to  explore  the  rectum  digitally.  A  rubber  glove  or  finger- 
cot  should  be  worn,  well  lubricated  with  vaselin.  The  exploring  finger 
should  break  up  the  masses,  if  soft  enough,  and  remove  whatever  is 
within  easy  reach.  This  procedure  should  be  followed  by  a  soap-suds 
enema.  Often  one  will  find  the  rectum  filled  with  masses  as  hard  as 
marbles,  worn  round  by  their  play  upon  each  other.  If  these  cannot 
be  broken  up,  the  smaller  may  be  removed  entire  by  the  finger;  the 
larger  will  necessitate  the  introduction  of  a  silver  spoon  or  a  gall-stone 
scoop.  If  this  procedure  is  attended  by  much  pain,  it  should  be  followed 
by  a  low  enema  of  6  oz.  of  starch  containing  10  drops  of  tincture  of 

opium. 

ENEMAS 

There  has  been  a  discussion  of  long  standing  as  to  the  relative  value 
of  catharsis  by  mouth  and  of  enemas  in  the  treatment  of  postoperative 
constipation.  It  has  been  shown '  that  after  abdominal  operations 
involving  the  alimentary  tract  the  enema  is  preferable.  General  peris- 
talsis is  excited  only  to  a  less  degree,  and  the  diseased  part  is  maintained 
at  rest.  The  large  intestine  is  kept  empty,  and  distention  with  gas, 
which  is  mostly  formed  in  the  colon,  is  rarely  considerable.  Hardened 
fecal  masses  cannot  remain  to  block  the  exit  of  gas  or  attempts  at  evac- 
uation. Straining  at  stool,  with  its  pull  on  abdominal  wound  and  on 
newly  forming  adhesions,  does  not  occur,  and  such  nourishment  by 
mouth  as  the  patient  has  been  induced  to  accept  is  not  unduly  hurried 
along  at  a  time  when  the  patient  needs  all  the  strength  he  can  acquire. 

Mild  Bnemas.— When  the  bowel  is  filled  higher  up  with  fecal 
matter,  it  will  become  necessary  to  employ  larger  quantities  of  fluid, 
to  insert  the  rectal  tube  further  into  the  rectum,  and  to  employ  somewhat 
greater  care  and  gentleness  in  making  the  injection,  so  as  to  insure  the 
fluid  being  carried  into  the  sigmoid  without  distending  the  rectum  and 
thus  exciting  a  desire  to  defecate.  Ordinarily  a  mild  enema  will  suffice 
to  induce  the  desired  action,  and  of  these  plain  water,  normal  salt  solu- 
tion, and  soapy  water  are  efficacious,  given  warm,  in  quantity  about  one 
pint  for  an  adult;  or  an  ounce  of  castor  oil  maybe  given  in  12  to  16  oz.  of 
thin  starch  solution.  Another  good  enema  is  milk  and  molasses,  equal 
parts  to  make  from  a  pint  to  a  quart. 

More  Drastic  Bnemas. — In  abdominal  cases  not  infrequently 
emergencies  arise  in  which,-  on  account  of  distention  or  intestinal  paresis, 
evacuation  of  the  colon  becomes  a  critical  necessity.     In  this  event 

^  Crandon,  Catharsis  in  x\bdominal  Surgery,  Boston  Med.  and  Surg.  Jour.,  1901, 
cxliv,  639. 


ENEMAS  149 

much  more  drastic  enemas  may  be  employed  in  conjunction  with  other 
means  of  exciting  peristalsis — enemas  so  irritative  that  their  use  should 
ordinarily  be  avoided.  Such  an  enema  is  the  suds  and  turpentine 
enema : 

Turpentine 2  ounces; 

Warm  suds 8       " 

This  mixture  must  be  stirred  continuously  while  it  is  being  given,  other- 
wise the  oil  will  float  on  top  and  the  patient  will  get  all  the  oil  in  the 
last  few  ounces.  Shaking  up  the  oil  first  with  half  its  bulk  of  mucilage 
of  acacia  or  white  of  egg  will  assist  in  holding  it  in  suspension.  Another 
combination  which  is  commonly  used  is: 

Turpentine, 
Glycerin, 

Epsom  salt aa  2  ounces; 

Warm  water  7        " 

The  turpentine  here  also  should  be  emulsified  with  the  white  of  one 
egg.  In  this  enema  the  proportion  of  turpentine  to  water  may  be 
increased  or  diminished  as  the  case  demands.  Before  any  enema  con- 
taining turpentine  is  administered,  the  region  about  the  anus,  as  well 
as  the  buttocks  and  sacrum,  should  be  well  oiled,  to  protect  the  skin 
from  blistering.  Heat  seems  to  have  an  important  influence  in  stimu- 
lating peristalsis,  and  for  this  reason  some  surgeons  are  in  the  habit 
of  injecting  into  the  colon  6  oz.  of  hot  olive  or  cotton-seed  oil  or  hot 
glycerin.  The  old-fashioned  milk  and  molasses  enema,  of  each  one 
pint,  if  given  high  and  hot,  is  usually  followed  by  good  results,  and  it 
is  not  so  irritating  as  the  enemas  depending  upon  turpentine  or  glycerin 
for  their  action. 

There  is  one  precaution  to  be  always  borne  in  mind  in  the  adminis- 
tration of  an  enema,  and  that  is,  to  see  that  due  care  is  exercised  in  the 
passing  of  the  tube.  If  the  rubber  rectal  tube  is  pushed  in  carelessly 
or  hurriedly,  the  tip  is  likely  to  catch  on  one  of  the  valves  of  Houston, 
and  the  tube  will  coil  up  within  the  rectum  and  perhaps  tear  or  injure 
the  valve.  For  a  high  injection  the  tube  should  always  be  passed 
slowly  and  with  great  gentleness,  upon  the  well-lubricated  gloved  fore- 
finger of  the  left  hand,  inserted  as  far  as  it  will  go.  If  the  patient  lies 
upon  his  left  side,  gravity  will  aid  in  guiding  the  tube  toward  the  sigmoid 
flexure.  A  valuable  contribution  to  the  question  of  the  practicability 
of  the  high  enema  is  that  of  Soper  (see  also  Chapter  XII,  p.  121). 
It  seems  to  be  the  belief  of  the  majority  of  physicians  that  the  soft- 
rubber  tube  can  be  passed  beyond  the  sigmoid  flexure,  though  this  has 


150  CARE    OF    THE    BOWELS 

been  disputed  by  high  authorities.  Soper's  experiments  and  the  ski- 
agrams show  that  in  many  cases,  perhaps  in  nearly  all,  the  tube  does 
not  pass  beyond  the  dome  of  the  rectum,  and  that  it  is  only  in  except 
tional  conditions  of  dilatation  and  hypertrophy  of  the  colon  that  it  can 
be  successfully  introduced  beyond  the  sigmoid  flexure.  If  it  could 
go  further,  there  is  still  difficulty  to  be  overcome  before  the  injection 
could  be  carried  anywhere  near  the  cecum,  as  some  have  claimed. 
The  need  of  introducing  the  injection-tube  beyond  the  rectum  is  prob- 
ably in  most  cases  an  imaginary  one.  Soper  himself  says  that  he  has 
frequently  demonstrated  the  possibility  of  flushing  the  entire  colon  by 
using  a  large-caliber  (^-in.)  short  tube.  It  is  certainly  much  easier 
to  depend  on  an  enema  finding  its  own  way  beyond  the  flexures  than 
to  endeavor  to  carry  it  beyond  them.  A  tube  of  sufficient  rigidity  to 
force  its  way  would  hardly  be  advisable  for  general  use,^  Soper  in 
the  same  issue  says,  "I  believe  that  it  is  only  in  those  rare  cases  of 
abnormal  development  of  the  sigmoid  that  it  is  possible  to  introduce  a 
soft-rubber  tube  higher  than  6  or  7  in.  in  the  rectum  without  it 
bending  or  coiling  on  itself.  With  the  aid  of  the  sigmoidoscope  only 
the  middle  of  the  sigmoid  can  be  reached.  The  practice  of  allowing 
liquids  to  flow  through  simultaneously  with  the  introduction  of  the  tube 
serves  to  smooth  out  the  kinks  and  adds  to  the  illusion  that  the  tube 
is  going  higher.  The  short  tube,  6  in.  in  length,  is  therefore  best 
for  all  sorts  of  enema  (a)  when  water,  etc.,  is  introduced  for  the  pur- 
pose of  causing  fecal  evacuations,  using  the  fountain  syringe  or  funnel 
and  long  tube  in  the  usual  way.  It  is  possible,  as  I  have  frequently 
demonstrated,  thoroughly  to  cleanse  the  entire  colon  by  using  a  large- 
caliber  (^  in.)  short  tube.  This  is  connected  by  rubber  tubing  with 
a  large  funnel,  elevated  from  3  to  4  ft.  above  the  patient,  pouring  in  the 
solution  until  he  experiences  a  feeling  of  distention  or  desire  to  evacu- 
ate, then  lowering  the  funnel  until  the  outflow  has  ceased,  repeating  this 
maneuver  in  exactly  the  same  manner  as  in  gastric  lavage. 

"  The  short  tube  is  also  best  (b)  when  retention  of  liquid  is  desired, 
as  in  administering  saline  solution,  oil,  nutrient  material,  etc.  The  at- 
tempt to  pass  the  tube  higher  into  the  bowels  is  not  only  unnecessary, 
but,  because  of  the  coiling  that  inevitably  occurs,  such  a  manipulation 
tends  to  produce  irritability  of  the  bowel.  This,  of  course,  will  very 
probably  cause  expulsion  of  the  fluid." 

After  any  operation  involving  the  lower  rectum,  as  after  a  prostatic 
enucleation,  a  Whitehead  or  a  Kraske,  care  must  be  exercised  lest  the 
thin  mucous  membrane  be  torn  by  the  tip  of  the  stiff  tube,  or  the  line 

^  Editorial,  Jour.  Anier.  Med.  Assoc,  liii,  Aug.  7,  1909. 


DISTENTION  I5I 

of  suture  separated,  and  the  enema  be  poured  into  the  peritoneal  cavity 
— ^\vhich  I  have  knovv^n  to  happen  with  fatal  result.  Likewise,  after 
any  operative  procedure  involving  a  suture  of.  the  intestine,  especially 
if  it  be  low  down  in  the  gastro-intestinal  tract,  enemas  must  be  post- 
poned until  it  is  felt  that  the  line  of  union  is  sound,  and  then  they  should 
be  given  gently  and  with  little  pressure.  Even  so,  retroperistalsis  may 
be  set  up,  which  will  carry  the  fluid  backward  with  considerable  force 
along  the  gastro-intestinal  tract. 

DISTENTION 

After  any  operation,  but  chiefly  after  celiotomies,  we  are  accustomed 
to  note  the  accumulation  of  a  moderate  amount  of  gas  in  the  gastro- 
intestinal tract.  This  distention  usually  involves  the  intestines  chiefly, 
but  it  may  be  limited  to  the  stomach.  The  occurrence  of  distention 
seems  to  be  about  in  proportion  to  the  amount  of  exposure  and  handling 
which  the  intestines  have  received. 

Gas  is  normally  present  in  some  amount  in  both  stomach  and  in- 
testines. This  normal  quantity  is  added  to  after  operation  by  the  fer- 
mentation of  such  food  as  remains  in  the  gastro-intestinal  tract.  If 
the  patient  has  been  well  cleaned  out  before  the  operation,  fermentation 
will  be  practically  nil.  In  addition,  there  seems  to  be  a  failure  on  the 
part  of  the  mucous  membrane  to  absorb  the  gas.  The  flatus  is  some- 
times increased  considerably  by  air  swallowing  or  "cribbing."  With 
some  persons  this  is  simply  a  nervous  habit;  after  operation  a  patient 
may  swallow  considerable  air  with  the  saliva  which  he  is  constantly 
gulping  down  to  relieve  the  parched  feeling  in  his  throat.  The  gas  ac- 
cumulates in  the  intestines  because  the  patient  will  not  relax  his  sphinc- 
ters to  release  it,  because  of  failure  of  peristalsis  to  expel  it,  and  because 
the  abdominal  muscles,  if  they  have  been  injured  by  the  surgeon's  in- 
cision, cannot  or  will  not  contract  to  assist  the  intestines.  As  the  volume 
of  gas  increases  the  intestines  become  inflated  and  stretched,  offering 
less  and  le-ss  resistance  to  the  expansion,  and  become  paralytic,  until 
they  lose  their  tone  entirely. 

Ordinarily  the  accumulation  of  flatus  is  simply  a  matter  of  discom- 
fort to  the  patient,  and  in  cases  other  than  abdominal  usually  responds 
to  simple  remedial  measures.  The  hard-rubber  rectal  nozzle  of  a 
household  syringe  may  be  passed,  well  lubricated,  through  the  sphinc- 
ters, and  worn  an  hour  at  a  time,  three  times  a  day,  usually  with  great 
relief.  To  encourage  the  belching  of  gas  accumulated  in  the  stomach 
one  should  try  one  or  another  carminative,  as  peppermint  water;  Hoff- 
man's anodyne,  20  minims,  on  cracked  ice;  or  5  drops  of  turpentine  on  a 


152  CARE    OF    THE    BOWELS 

lump  of  sugar.  Position  seems  to  have  an  important  influence  on  the  ac- 
cumulation of  gas;  allowing  the  patient  to  turn  upon  his  left  side  and 
to  draw  up  his  knees  wi^l  render  easier  the  passage  of  flatus.  ^Slassage 
of  the  abdomen  is  an  efficient  aid  in  promoting  peristalsis,  especially 
in  persons  with  flabby  abdominal  ■  walls.  As  the  first  evacuation  of 
the  bowels  usually  carries  off  with  it  the  gas  which  has  accumulated 
since  the  operation,  the  bowels  should  be  moved  as  soon  as  conditions 
indicate.  For  this  purpose  castor  oil,  calomel,  or  Epsom  salt  may  be 
given  by  mouth  or  an  enema  of  soap-suds  administered. 

After  celiotomies  distention  may  have  a  serious  significance,  and, 
besides  being  so  frequently  a  forerunner  of  peritonitis,  is  always  of 
itself  a  source  of  anxiety  to  the  surgeon.  The  tendency  for  flatus  to 
accumulate  is  always  increased  and  the  bowel  is  less  able  to  expel  thf 
collected  gas.  Distention  goes  on  until  the  bowel-wall  becomes  para- 
lyzed, and  this  may  prove  fatal  in  itself,  or  a  fatal  termination  may  result 
from  a  kinking  of  the  dilated  intestine.  The  diaphragm  is  driven  up, 
and  may  seriously  impede  the  action  of  the  heart  and  lungs.  In  any 
abdominal  case  the  surgeon  should  percuss  the  abdomen  at  each  visit, 
until  the  bowels  have  acted,  to  satisfy  himself  that  there  is  no  over- 
distention.  This  can  be  satisfactorily  done,  as  a  rule,  through  the 
swathe;  if  there  is  any  question,  the  swathe  should  be  removed.  If 
the  gas  has  not  been  freely  passed  within  tvventy-four  hours  after 
the  operation,  the  simpler  measures  detailed  above  should  be  put  into 
play.  If  these  fail  to  act,  or  the  distention  increases,  no  time  should 
be  lost  in  bringing  to  bear  every  means  of  forestalling  a  possible  fatal 
meteorism. 

In  paralytic  distention  purgation  by  mouth  generally  fails  to  act 
and  may  aggravate  the  existing  condition  by  stimulating  the  secretion 
of  intestinal  fluids.  We  should  rely  chiefly,  therefore,  upon  drastic 
enemas,  given  high  and  frequently  and  in  large  amount.  Of  these, 
the  best  are  the  turpentine  and  suds,  the  turpentine,  Epsom  salt,  and 
glycerin,  the  milk  and  molasses,  and  the  hot  glycerin.  Another  enema 
which  has  a  good  reputation  in  the  removal  of  flatus  is  the  enema  of 
asafetida : 

Tincture  of  asafetida 6  drams; 

Warm  thin  starch-water • 8  ounces. 

These  act  to  empty  the  large  bowel  of  gas  and  so  encourage  more 
to  descend  from  the  small  intestine  The  rectal  tube  should  be  passed 
as  high  as  it  will  go  freely  without  kinking,  and  left  in  place  to  allow 
a  free  exit  for  gas.    If  there  is  no  marked  relief  following  the  first  enema, 


DISTENTION 


15: 


6  oz.  of  hot  cotton-seed  oil  should  be  injected  through  the  tube  every 
hour,  and  every  fourth  hour  another  enema  administered.  In  addition, 
peristalsis  should  be  stimulated  by  external  applications,  either  of  heat, 
in  the  form  of  flax-seed  poultices  or  turpentine  stupes,  covering  the 
entire  abdomen,  repeated  every  two  hours,  or  cold,  in  the  form  of  ice- 
bags.  As  the  distended  abdominal  wall  is  insensitive  and  seems  par- 
ticularly easy  to  burn,  the  skin  should  be  greased  with  oil  or  vaselin 
before  the  application.  Turpentine  stupes  are  made  by  wringing 
out  old  flannels  or  squares  of  blanket  in  hot  water  to  which  turpentine 
has  been  added  in  the  proportion  of  about  a  tablespoonful  to  the  quart. 
Another  maneuver,  which  is  often  followed  by  good  results,  is  to  run 
slowly  a  lighted  wax  taper  or  a  Paquelin  cautery  tip  heated  to  a  dull 
red  over  the  abdomen,  just  close  enough  to  the  skin  to  burn  the  hairs, 
beginning  at  the  cecum,  following  up  the  ascending,  across  the  trans- 
verse, and  down  the  descending  colon.  Apparently  the  concentration 
of  heat  over  a  small  area  has  some  effect  on  exciting  peristalsis;  what 
part  the  mental  effect  plays  cannot  be  definitely  stated.  In  addition, 
strychnin  may  be  given  hypodermically,  on  the  theory  that  it  increases 
the  activity  of  the  alimentary  tract.  Atropin  is  sometimes  advocated, 
as  it  is  given  in  various  forms  of  colic,  to  lessen  spasm  and  to  allow 
the  passage  of  intestinal  contents.  Postoperative  tympanites,  however, 
is  rarely  if  ever  due  to  spasm,  but  rather  to  paralysis,  and  atropin  acts 
but  to  increase  this  paralysis.  Eserin  salicylate  is  highly  commended 
by  some  surgeons.  It  is  ordinarily  given  during  or  after  the  opera- 
tion, in  the  dose  of  ^^  gr.     I  have  had  no  experience  with  it.^ 

^  D.  C.  Craig,  of  Boston,  has  used  this  drug  exclusively  and  speaks  highly  of  it  (The  Pre- 
vention of  Postoperative  Intestinal  Paresis  and  Adhesions,  Amer.  Jour,  of  Obstet.,  etc.,  April, 
1904;  The  After-treatment  of  Abdominal  Sections  with  Eserin  Salicylate,  New  York  Med. 
Jour.,  March  13, 1905).  If  the  patient  is  known  to  react  readily  to  cathartics,  he  uses  -^  gr.; 
if  she  is  of  a  constipated  habit,  -g'-^  gr.;  when  atony  of  the  intestinal  muscles  exists,  he  gives 
up  to  2^(j.  The  medium  dose  is  -^-q,  to  be  repeated  on  the  first  indication  that  it  is  inadequate. 
It  should  always  be  given  with  atropin,  which  antagonizes  all  the  undesirable  actions  of  the 
eserin.  The  atropin  should  be  given  first,  because  it  acts  more  slowly.  The  best  time  to 
give  it  is  just  before  the  operation,  gr.  y-g-g-,  subcutaneously.  The  eserin  is  injected  under 
the  skin  after  the  abdomen  is  opened,  as  soon  as  it  is  evident  that  no  contra-indication  exists, 
such  as  would  demand  absolute  intestinal  rest  and  quiet.  It  should  be  withheld,  therefore, 
in  cases  where  strong  or  numerous  adhesions  are  encountered,  until  it  is  e\ident  that  the 
adhesions  may  be  freed  without  damage  to  the  intestinal  musculature.  Its  use  is  contra- 
indicated  in  cases  of  intestinal  anastomosis-or  resection,  and  whenever  we  are  led  to  suspect 
that  some  more  or  less  septic  material  is  being  left  behind  in  the  peritoneal  ca^^ty,  until 
healing  is  well  established. 

Moennighoff  (Postoperative  Gas  Distention  of  the  Abdomen  with  Suggestions  for 
Prevention,  Jour.  Missouri  State  Med.  Assoc,  Oct.,  1908)  uses  eserin  salicylate  hypoderm- 
ically in  celiotomies  as  a  prophylactic  against  distention,  giving  gr.  ^'g  immediately 
after  the  patient  has  returned  to  bed. 


154  CARE   OF   THE   BOWELS 

There  may  arise  an  acute  postoperative  dilatation  of  the  stomach 
and  duodenum,  apart  from  dilatation  of  the  intestines.  It  has  been 
produced  experimentally  by  exerting  traction  on  the  mesentery,  but  air- 
swallowing,  drinking  excessive  quantities  of  water,  or  sepsis  may  be  an 
element  in  its  causation.  Its  onset  is  sudden,  with  pain  and  vomiting, 
which  is  usually  not  fecal,  and  distention,  which  gives  the  succussion 
sound  if  any  fluid  is  present  in  the  stomach.  The  pulse  and  tempera- 
ture rise  and  there  is  a  rapidly  developing  collapse.  The  condition 
cannot  be  readily  distinguished  from  acute  obstruction;  diagnosis  is 
made,  in  suspected  cases,  by  the  succussion  and  the  absence  of  any 
fecal  quality  to  the  vomiting.  Chronic  cases  develop  more  slowly 
but  show  the  same  signs.  About  70  per  cent,  die  if  untreated,  probably 
in  many  cases  from  pressure  of  the  enlarged  stomach  upon  the  heart. 
Vomiting  should  be  encouraged.  A  stomach-tube  should  be  passed 
and  left  in  situ,  and  every  three  or  four  hours  the  stomach  washed  out. 
The  passage  of  the  tube  will  be  followed  by  the  forcible  expulsion  of 
gas  and  fluid  with  immediate  relief.  The  foot  of  the  bed  should  be 
elevated  and  the  patient  fed  only  by  rectum.  In  any  obstinate  case 
of  tympanites  a  tube  should  be  passed  into  the  stomach  to  relieve  it  of 
accumulated  gas,  for  in  a  given  case  it  is  usually  difl&cult  to  differentiate 
distention  of  the  stomach  and  intestines.  (For  details  of  this  complica- 
tion see  Chapter  XVI,  p.  156.) 

An  unrelievable  tympanites  may  represent  a  distention  of  the  in- 
testines behind  a  kink,  which  constitutes  a  true  intestinal  obstruction 
and  tends  to  a  fatal  termination.  Frequently  distention  is  the  initial 
sign  of  peritonitis.^  Sometimes  patients  die  with  distention  and  no 
peritonitis,  or  only  a  beginning  peritonitis  is  evident  at  autopsy.  It 
is  clear  in  these  cases  that  death  is  not  the  result  of  peritonitis.  Death 
in  cases  of  simple  distention  must  be  due  to  the  absorption  of  toxic 
products  elaborated  in  the  intestinal  tract,  or  to  the  peritoneal  absorp- 
tion of  the  toxic  products  of  bacteria,  which  have  made  their  way  through 
the  stretched  and  atonic  intestinal  wall,  without  exciting  inflammatory 
reaction  in  the  peritoneiun.  itself.  On  account  of  these  possibilities 
any  case  of  postoperative  t}^mpanites  which  progresses  in  spite  of  treat- 
ment should  be  considered  operative.  So  long  as  the  abdominal  wall 
remains  soft,  the  patient  being  in  good  condition,  there  is  hope  of  ob- 

^  Heile  (Prophylactic  Treatment  of  Inflammatory  Ileus,  Central,  f.  Chir.,  vol.  xxx^'i. 
No.  31,  July  31,  1909)  states  that  in  all  cases  of  dififuse  peritonitis  he  stimulates  peris- 
talsis by  injecting  50  to  100  cc.  of  warm  castor  oil  directly  into  a  high  loop  of  the  small 
intestine  before  closing  the  abdomen.  A  silk  draw-thread  closes  the  small  hole  made  by 
the  needle  used  in  injecting  the  castor  oil.  It  works  more  effectively  if  emulsified  with  a 
little  soda  and  water. 


DISTENTION  1 55 

taining  response  to  treatment.  If  the  abdominal  wall  becomes  tense 
and  hard,  and  the  general  condition  begins  to  fail,  operative  measures 
should  not  be  delayed.  The  best  method  of  procedure  is  to  treat  the 
case  as  one  of  acute  postoperative  intestinal  obstruction  along  lines  to 
be  detailed  later.  There  have  been  advocates,  in  the  past,  of  simple 
puncture  of  the  intestine  by  means  of  a  fine  trocar  or  long  hypodermic 
needle  shoved  at  random  through  the  abdominal  wall  into  the  intestine 
for  the  purpose  of  allowing  the  escape  of  gas,  and  recoveries  after  this 
procedure  have  been  published.  The  method  is  unsurgical  and  the 
danger  of  setting  up  a  peritonitis  from  leakage  about  the  trocar  is  great. 
Moreover,  the  intestine  must  usually  be  punctured  in  several  places  and 
many  times,  because  each  puncture  will  relieve  but  one  loop  of  gut  and 
the  gut  above  and  below  will  be  shut  off  by  kinking.  The  procedure  is  in- 
dicated practically  only  in  moribund  cases  where  an  extreme  distention 
is  causing  excruciating  pain.  It  shall  be  performed  in  the  flank  over 
the  cecum,  because  this  is  a  fixed  point  and  will  not  give  rise  to  kinking. 
A  puncture  here  will  relieve  the  colon,  and  may  also  relieve  the  small 
intestine  gradually  through  the  ileocecal  valve.  The  trocar  or  needle 
may  be  left  in  situ  for  some  while.  If  there  is  a  leakage  of  intestinal 
contents  at  this  point,  it  is  less  likely  to  spread  over  the  peritoneal  cavity 
and  it  may  waU  off. 


CHAPTER  XVI 

ACUTE    INTESTINAL    OBSTRUCTION;   ACUTE   GASTRIC 

DILATATION 

ACUTE  INTESTINAL  OBSTRUCTION 

Acute  intestinal  obstruction  is  one  of  the  most  discomforting  of 
the  sequelae  which  the  abdominal  surgeon  has  to  face.  Its  occurrence 
is  not  infrequent  and  the  mortality  is  high/  Two  forms  are  ordinarily 
recognized,  the  mechanical  and  the  septic.-  Finney^  speaks  also  of 
an  adynamic  type,  but  this  we  have  already  considered  under  the  name 
of  paralytic  distention. 

Mechanical  obstruction  is  usually  caused  by  adhesions.  It  may  re- 
sult from  kinks  or  twusts  of  the  intestine  upon  its  mesentery,  by  intus- 
susception at  the  point  of  an  intestinal  anastomosis,  by  the  hernia  of 
a  knuckle  of  gut  through  an  opening  in  the  mesentery,  or  by  pressure 
from  a  drain.  It  occurs  most  frequently  in  cases  of  local  or  general 
peritonitis  where  there  has  been  a  formation  of  adhesion  bands.  It 
occurs  commonly  after  drained  appendectomies  where  a  few  firm  ad- 
hesions have  united  the  cecum  and  an  adjacent  loop  of  small  intestine. 

The  onset  of  symptoms  is  usually  late — from  three  to  nine  days 
after  operation — and  sudden  in  appearance.  There  may  or  may  not 
be  severe  colicky  pains.  The  passage  of  flatus  ceases  and  distention 
develops.  The  distention  is  apt  to  be  asymmetric,  with  visible  peris- 
talsis of  the  distended  coils.  Rectal  enemas  come  back  as  they  went 
in.  Vomiting  appears  early  and  rapidly  becomes  fecal  in  nature.  The 
case  at  first  will  suggest  peritonitis,  but  this  usually  can  be  differentiated 
by  the  lateness  of  the  onset  and  by  the  absence  of  notable  rise  in  pulse 
or  temperature. 

The  term  septic  obstruction  is  one  that  is  given  to  the  condition  which 
follows  upon  the  development  of  general  suppurative  peritonitis.  This 
form  is  likely  to  manifest  itself  immediately  after  any  celiotomy  which  dis- 
closes a  diffuse  septic  peritonitis.  The  formation  of  adhesions  seems  to 
take  no  part  in  the  causation  of  this  form  of  obstruction;  the  intestinal  stasis 
can  be  referred  partly  to  a  disturbed  innervation  of  the  intestinal  wall 

^  Gibson,  Ann.  Surg.,  Oct.,  1900,  xxix,  places  it  at  47  per  cent. 
^  Forbes  Hawkes,  The  Prevention  of  Intestinal  Obstruction  Following  Operation  for 
Appendicitis,  Ann.  Surg.,  1909,  xlix,  192. 
^  Ann.  Surg.,  June,  1906,  xliii. 

156 


ACUTE    GASTRIC    DILATATION  1 57 

from  septic  intoxication,  and  partly  to  the  formation  of  massive  flakes 
of  fibrin  and  the  cohesion  of  coil  to  coil.  This  form  of  obstruction 
should  be  forestalled  by  instituting  intestinal  drainage  at  the  time  of 
operation  in  all  cases  of  spreading  septic  peritonitis.  Through  a  grid- 
iron incision  in  the  flank  the  ileum  should  be  seized  as  low  down  as 
possible,  incised,  and  drained  through  a  Paul  tube.  If  one  waits  for 
fecal  vomiting  before  performing  a  secondary  operation,  the  effort  is 
usually  wasted. 

The  question  of  when  to  operate  in  any  form  of  postoperative  ob- 
struction is  usually  not  easy  to  decide  in  the  individual  case.  This 
difficulty  may  be  referred  chiefly  to  the  doubt  that  frequently  arises 
over  the  diagnosis.  Usually  by  the  time  that  the  symptoms  have  de- 
veloped sufficiently  so  that  there  is  no  question  about  the  diagnosis,  the 
chance  of  recovery  is  small.  If,  after  a  fair  deliberate  consideration 
of  the  symptoms,  the  probability  of  acute  intestinal  obstruction  seems 
established,  operation  should  be  performed  immediately.  The  follow- 
ing signs  and  symptoms  are  to  be  considered  as  incriminating  evidence: 

(i)  Distention,  with  or  without  vomiting. 

(2)  Local  pain  or  tenderness,  which  is  extending. 

(3)  Increasing  resistance  or  rigidity. 

(4)  Chills. 

.(5)  An  increasing  pulse-rate,  without  a  corresponding  elevation 
of  temperature. 

(6)  The  peritoneal  facies. 

The  question  of  whether  to  operate  can  be  dismissed  in  a  line.  In 
the  words  of  Sir  Frederick  Treves,  "There  is  no  avoiding  the  fact  that 
acute  intestinal  obstruction  if  unrelieved  ends  in  death."  .  Delay  is  far 
more  serious  than  operation,  which  is  not  to  be  considered  as  the  last 
resort,  but  rather  as  the  first  resource. 

The  extent  of  the  operative  procedure  will  depend  upon  the  condition 
of  the  patient.  If  the  operation  is  undertaken  early  with  the  patient 
in  fair  condition,  without  distention,  a  careful  search  should  be  made 
to  unearth  and  relieve  the  cause  of  trouble.  On  the  contrary,  with 
the  patient  in  bad  condition,  a  rapidly  accomplished  enterostomy  per- 
formed as  low  down  as  possible,  under  cocain  anesthesia,  may  be  the 
most  radical  course  which  can  be  considered. 

ACUTE  GASTRIC  DILATATION 

An  acute  dilatation  of  the  stomach  (gastrectasia,  gastric  paresis, 
gastromesenteric  ileus)  may  follow  operation.  The  condition  is  anal- 
ogous to  distention  of  the  small  intestine,  which  it  frequently  accompanies, 


158    ACUTE   INTESTINAL   OBSTRUCTION;   ACUTE   GASTRIC   DILATATION 

and  in  the  majority  of  the  cases  probably  represents  a  reflex  paresis. 
Some  investigators  claim  that  it  is  due  to  occlusion  of  the  duodenum 
from  the  pressure  of  the  mesentery  which  overlies  it,  and  that  the  dila- 
tation and  ptosis  of  the  stomach  are  secondary.  As  this  condition  (called 
duodenal  ileus  or  gastromesenteric  ileus)  is  usually  to  be  definitely 
diagnosticated  only  at  autopsy,  it  will  remain  difficult  to  determine 
finally  in  the  individual  case  W'hether  the  dilatation  and  ptosis  cause 
kinking  and  occlusion  at  the  duodenum,  or  whether  the  weight  of  the 
small  intestine  dragging  on  the  root  of  the  mesentery  causes  the  occlusion 
and  secondary  dilatation. 

The  importance  of  this  acute  and  serious  complication  of  abdominal 
section  has  only  come  to  be  understood  within  the  past  ten  years,  and 
it  is  still  more  recently  that  we  have  begun  to  pay  attention  to  its  treatment. 
Recent  discussion  has  convinced  us  that  it  occurs  much  more  fre- 
quently than  we  formerly  supposed,  and  that  in  itself  it  is  very  likely 
to  cause  death.  The  possibility  of  its  occurrence  must  be  borne  in 
mind  in  the  after-care  of  any  case  in  which  abdominal  symptoms  present 
themselves. 

Polak^  found  that  it  was  recognized  in  -^jy  of  i  per  cent,  of  1000 
celiotomies  Laffer  ^  has  recently  collected  97  cases  after  operation; 
69  per  cent,  of  these  occurred  after  laparotomies.  It  was  most  frequent 
after  operations  on  the  biliary  system,  next  after  operations  on  the 
kidney,  and  less  frequent  after  appendectomies,  curettage,  uterine 
operations,  herniotomies,  operations  on  the  stomach  and  on  the  extremi- 
ties. 

The  significance  'of  anesthesia  in  its  production  is  still  undetermined. 
Laffer  states  that  in  20  cases  where  the  anesthetic  was  recorded  chloro- 
form was  used  t\velve  times  and  ether  eight.  Lichtenstein  ^  states  that 
it  may  occur  when  no  anesthetic  has  been  used. 

It  is  said  to  be  common  in  thin,  weakly  indi\nduals,  especially  those 
with  general  enteroptosis.*  Abdominal  trauma,  errors  of  diet,  the 
accumulation  of  gas  due  to  fermentation  of  retained  foods,  drinking 
a  large  quantity  of  fluids,  especially  carbonated  waters,  and  tight  ab- 
dominal binders  have  all  been  blamed  as  the  source  of  this  complica- 
tion.    Connor  ^  makes  the  statement  that  obstruction  of  the  duodenum 

^  Acute  Gastric  Dilatation  as  a  Postoperative  Complication,  New  York  Med.  Jour., 
1909,  Ixxxix,  1 1 84. 

^  Acute  Dilatation  of  the  Stoma'ch  and  Arteriomesenteric  Ileus,  Ann.  Surg.,  1908, 
xlvii,  533. 

^  Akute  Magenlahmung,  Central,  f.  Gyn.,  1908,  xxxiii,  615. 

^  Borchardt,  Akute  Magenektasie..  Berlin,  klin.  Woch.,  1908,  xlv,  1593. 

^  Amer.  Jour.  Med.  Sci.,  1907,  cxxx,  345. 


ACUTE    GASTRIC    DILATATION  1 59 

by  the  overlying  mesentery  must  be  regarded  as  a  factor  in  the  develop- 
ment of  one-third  to  one-half  of  all  cases  of  acute  gastrectasia,  and  Polak 
{op.  cit.)  states  that  there  can  be  no  doubt  but  that  the  Fowler  posture 
favors  constriction  of  the  lower  end  of  the  duodenum  between  the  root 
of  the  mesentery  and  the  vertebral  column.  Peritonitis  may  be  a  factor 
in  certain  cases. 

The  onset  of  the  first  symptom — vomiting — is  usually  toward  the 
end  of  the  first  twenty-four  hours  after  operation.  It  practically  always 
occurs  within  thirty-six  hours.  I  have  twice  known  acute  dilatation 
to  occur  before  sewing  up  the  abdominal  wall — once  in  my  own  practice, 
once  in  a  case  of  Dr.  Torbert's,^  both  during  Cesarean  section.  The 
dilatation  was  sudden  and  enormous,  the  stomach  practically  half  filling 
the  entire  peritoneal  cavity.  In  the  first  case  the  stomach  was  emptied 
by  gentle  and  persistent  pressure,  in  the  second  by  incision  through 
the  stomach-wall.     Both  cases  recovered  without  untoward  symptoms. 

The  vomiting  is  the  first  symptom  to  attract  attention.  It  occurs 
in  90  per  cent,  of  the  cases.  The  few  cases  in  which  no  vomiting  occurs 
are  apt  to  end  fatally.  The  vomitus  is  copious  in  quantity — apparently 
much  in  excess  of  the  amount  of  fluid  taken.  It  is  usually  continuous.  It 
comes  up  in  gulps,  without  strain  or  effort,  in  quantities  of  8  to  12 
oz.  In  nature  it  is  yellowish  green,  or  sometimes  brown  or  black, 
sour  smelling,  but  rarely  ever  feculent. 

Signs  of  collapse  occur  early,  and  they  depend,  among  other  things, 
on  the  loss  of  body  fluids,  toxemia,  and  interference  with  respiration 
and  cardiac  action  by  upward  pressure  of  the  dilated  stomach. 

Distention  of  the  abdomen  appears  first  in  the  upper  half  of  the 
abdomen,  soon  becoming  general.  Sometimes  in  early  cases  the  lower 
border  of  the  stomach  can  be  outlined  by  the  peculiar  quality  of  the 
percussion  tympany,  which  may  even  replace  to  some  extent  the  normal 
cardiac  dulness.  Splashing  sounds  in  the  stomach  can  frequently  be 
elicited  on  rocking  the  patient  from  side  to  side.  The  distention  may 
be  so  gre^t  as  to  tear  out  the  abdominal  sutures.  It  is  usually  unac- 
companied by  tenderness  or  rigidity  except  toward  the  end. 

Diffuse  abdominal  pain  is  usually  present  in  a  severe  form,  increas- 
ing with  and  depending  on  the  amount  of  distention.  Thirst  is  usually 
present  and  may  be  agonizing.  The  temperature  rises  little  or  not  at  all, 
and  as  the  signs  of  collapse  increase,  it  may  become  subnormal.  There 
is  a  shght  and  gradual  increase  in  the  pulse  and  respiratory  rate  as  the 
distention  increases;  if  this  is  relieved,  the  pulse  and  respiratory  rate 
fall.     The  bowels  are  usually  in  a  state  of  constipation. 

^  Boston  Med.  and  Surg.  Jour.,  Aug.  12,  1909. 


l6o    ACUTE    INTESTINAL    OBSTRUCTION;    ACUTE    GASTRIC    DILATATION 

The  diagnosis  is  difficult  only  to  the  surgeon  who  has  never 
recognized  a  case.  It  is  usually  confounded  with  peritonitis,  para- 
lytic distention,  or  acute  intestinal  obstruction.  The  persistent  vomit- 
ing in  gulps  without  effort  of  olive-green  vomitus,  which  does  not  be- 
come feculent,  is  characteristic.  The  marked  degree  of  distention, 
with  no  rigidity,  little  if  any  tenderness,  and  considerable  pain,  in  the 
presence  of  the  succussion  splash,  are  pathognomonic.  The  normal 
or  subnormal  temperature  accompanying  signs  of  collapse  serves  to  differ- 
entiate it  from  peritonitis.  The  diagnosis  can  be  made  absolute  by  the 
passage  of  the  stomach-tube. 

Of  a  series  of  217  cases  from  all  causes,  63  J  per  cent,  died 
(Lafifer). 

It  is  evident  that  prophylaxis  assumes  immediately  a  position  of 
importance.  Wherever  dilatation  of  the  stomach  is  known  to  exist 
before  operation,  and  in  any  case  in  which  the  complication  might  be 
expected,  particular  care  should  be  taken  in  the  matter  of  postoperative 
diet.  No  large  meals  should  be  allowed  while  the  patient  is  in  bed. 
Water  should  be  given  in  small  quantities  and  at  first  only  subcutane- 
ously  or  by  enema.  The  patient  should  be  made  to  assume  a  position 
upon  the  side  or  abdomen  as  much  as  possible. 

Previous  to  any  celiotomy  food  should  be  restricted  for  forty-eight 
hours,  especially  with  reference  to  weight  and  the  amount  of  liquids, 
and  purgatives  should  not  be  used  immediately  before  operation.  Hand- 
ling of  the  stomach,  and  particularly  pulling  on  the  pylorus,  as  has  been 
shown  by  Kennan,^  favors  shock  and  gastro-intestinal  paralysis.  Cooling 
of  the  viscera  should  be  avoided  in  all  celiotomies  as  well  as  rough 
sponging  and  gauze  packing.  It  is  important  that  the  quantity  of 
anesthetic  be  limited  to  the  least  possible  amount,  because  the  ether 
which  is  reexcreted  in  the  stomach  may  be  a  factor  of  some  importance. 
The  swallowing  of  mucus  should  be  avoided  so  far  as  possible  by  wip- 
ing out  the  mouth  occasionally  with  gauze.  The  use  of  atropin  before 
operation  will  usually  limit  the  secretion  of  mucus.  Sometimes  it 
seems  probable  that  the  irritation  from  the  presence  of  a  drain  in  the 
neighborhood  of  the  duodenum,  such  as  might  be  introduced  after 
operations  upon  the  gall-bladder  or  its  ducts,  has  some  causal  influence 
in  setting  up  gastric  dilatation.  When  suggestive  symptoms  occur,  such 
a  drain  should  always  be  loosened  and  removed.  It  is  Avell  also  to 
remember  that  acute  dilatation  is  reported  as  not  infrequently  following 
the  application  of  a  plaster-jacket  for  Pott's  disease  of  the  spine. 

Treatment. — Cases    of   acute    dilatation   of   the    stomach   when 

^  Gastro-enterostomy  and  P3-loropIasty,  Ann.  Surg.,  1905,  690. 


ACUTE    GASTRIC    DILATATION:    TREATMENT  l6l 

recognized  early  usually  respond  promptly  and  effectually  to  treatment. 
All  food  by  mouth  should  be  stopped  and  the  stomach-tube  should  be 
put  into  service  at  once,  no  matter  how  badly  off  the  patient  seems. 
The  stomach  should  be  emptied  completely  and  promptly  and  it  should 
be  emptied  repeatedly.  Between  the  periods  of.  gastric  siphonage  the 
patient  should  be  made  to  lie  on  her  abdomen,  or,  if  this  is  impracticable, 
should  be  placed  in  the  exaggerated  Trendelenburg  position. 

Complete  emptying  of  the  stomach  in  its  dilated  condition  is  some- 
times difficult.  The  fluid  may  be,  and  often  is,  down  as  far  as  the  pelvis. 
It  is  a  good  plan  to  pass  the  tube  so  far  in  that  we  are  sure  that  it  has 
reached  the  level  of  the  fluid  and  then  place  the  patient  in  the  knee- 
chest  position  and  siphon  off  as  much  as  will  come  away  in  this  position, 
withdrawing  the  tube  slowly  so  as  to  allow  all  the  fluid  to  run  out. 
The  abdomen  should  then  be  tightly  bound  in  a  swathe. 

Saline  solution  under  the  skin  or  by  rectum  should  be  given  freely. 
Morphin  in  small  doses  must  be  given  when  indications  arise.  Stro- 
phanthin,  gr.  -^,  may  be  indicated  by  a  failing  pulse.  Some  authori- 
ties speak  highly  in  favor  of  the  repeated  lavage  of  the  stomach  with 
normal  salt  solution  or  sodium  bicarbonate.  Ordinarily  this  would 
seem  to  be  contra-indicated.  If  the  stomach  can  once  be  emptied  by 
means  of  posture  and  siphonage  through  the  stomach-tube,  and  is  kept 
emptied  through  the  agency  of  an  abdominal  swathe  and  the  forbiddance 
of  anything  by  mouth,  as  well  as  occasional  repetition  of  the  siphonage, 
the  patient  may  be  expected  to  recover. 
11 


CHAPTER  XVII 

BURSTING  OF  THE  ABDOMINAL  WOUND 

The  accidental  reopening  of  a  celiotomy  wound  may  result  from 
infection  of  the  wound  or  from  purely  mechanical  causes.  The  accident 
is  infrequent.  It  occurs  usually  after  a  median  incision  of  some  length 
and  least  often  when  the  wound  has  been  sewed  up  in  layers.  Instances 
are  on  record  where  a  wound  has  reopened  within  a  few  hours  of  the 
operation,  during  a  fit  of  coughing  or  vomiting  or  following  an  attempt 
on  the  part  of  the  patient  to  sit  himself  up  in  bed.  Sometimes  the 
exercises  of  a  patient  in  delirium  will  result  in  a  bursting  of  some  of  the 
sutures  in  a  wound  which  has  been  united  by  mass  (through-and-through) 
sutures.  Sometimes  there  is  apparent  lack  of  union  between  the  layers 
of  the  abdominal  wound,  probably  on  account  of  faulty  apposition, 
and  in  these  cases  the  wound  has  been  known  to  reopen,  after  removal 
of  the  sutures,  as  late  as  the  eighth  or  tenth  day. 

A  woman  of  thirty  had  a  median  incision  from  umbilicus  to  pubes  for  a 
pelvic  tumor.  On  account  of  poor  condition  at  the  end  of  operation  the 
wound  was  closed  by  through-and-through  sutures.  The  stitches  were  re- 
moved on  the  eleventh  day,  but  no  adhesive  strips  were  put  on  afterward. 
Half  an  hour  later  a  coughing  effort  split  the  whole  length  of  the  wound  and 
the  entire  intestinal  mass  came  out  into  the  bed.  The  patient  died  of  the 
shock  within  one  hour. 

The  element  of  sepsis  may  be  important  in  preventing  the  firm 
adhesion  of  the  wound  edges.  Sometimes  simply  the  outer  layers 
of  the  abdominal  wound  may  separate.  This  will  be  followed  by  a  hernia 
of  the  bowel  covered  with  peritoneum  and  fascia.  Reopening  of  the 
wound  from  sepsis  is  now  fortunately  uncommon.  The  use  of  the 
muscle-splitting  incision  and  of  the  right  rectus  incision  wherever  these 
are  practicable  obviates  in  a  large  degree  the  possibility  of  the  bursting 
of  the  wound  in  ordinary  cases.  Wherever  a  long  median  incision, 
however,  has  to  be  used,  especially  if  the  edges  are  held  approximated 
only  by  through-and-through  sutures  of  silk-worm  gut,  the  possibility 
of  reopening  of  the  wound  must  not  be  forgotten.  The  patient  must  be 
compelled  to  lie  quietly,  coughing  and  vomiting  should  be  controlled 

162 


BURSTING    OF   THE   ABDOMINAL   WOUND  1 63 

SO  far  as  possible,  and  due  care  should  be  exercised  in  transferring  the 
patient  from  one  bed  to  another  if  this  becomes  necessary.  The  sutures 
should  always  in  these  cases  be  reinforced  by  stripes  of  zinc  oxid  adhe- 
sive plaster,  going  across  the  abdomen  from  loin  to  loin. 

In  case  the  wound  should  accidentally  give  way  and  the  intestines 
protrude,  a  dry  sterile  dressing  should  at  once  be  applied.  The  nurse 
should  then  sit  on  the  bed  and  so  hold  and  control  the  hernia  mass 
(covered  by  sterile  dressing)  that  no  more  shall  protrude  till  the  surgeon 
arrives.  If  the  parts  are  sterile  and  the  wound  has  been  covered  by  a 
sterile  dressing  since  the  operation,  nothing  should  be  done  until  the 
surgeon  appears.  Then,  with  aseptic  precautions,  the  bowel  should 
be  returned  into  the  abdominal  cavity.  Under  cocain  a  few  sutures 
should  be  inserted  to  close  the  wound  and  reliance  should  be  placed 
upon  strips  of  adhesive  plaster  to  prevent  the  accident  from  recurring. 
Sometimes  this  occurrence  is  accompanied  by  a  considerable  shock  to 
the  patient,  but  the  accident  in  itself  need  not  be  serious.  If  the  parts 
are  jiot  sterile,  great  care  should  be  exercised  in  seeing  that  the  bowel 
is  thoroughly  washed  with  warm  saline  solution  before  it  is  replaced. 
If  only  a  small  tab  of  omentum  protrudes,  which  sometimes  happens, 
this  may  be  tied  off  and  the  incision  closed. 

Failure  of  the  carefully  sutured  abdominal  incision  to  unite  is  sometimes 
referred  to  a  local  anemia  of  the  healing  line  resulting  from  internal  pres- 
sure, as  in  distention  (C.  H,  Mayo),  trophic  disturbances  (T.  C.  Wither- 
spoon),  as  well  as  sepsis  and  constitutional  dyscrasias,  such  as  chronic 
nephritis  and  anemia  (C.  H.  Wallace).^ 

^  Jour.  Amer.  Med.  Assoc,  1910,  liv,  148,  149. 


CHAPTER  XVIII 

SEQUELS     OF     THE     ANESTHESIA:     CONJUNCTIVITIS, 
ETC.,  PNEUMONIA,  NEPHRITIS 

Sore  Jaw. — ^There  are  some  minor  inconveniences  which  a  patient 
is  liable  to  experience  as  a  direct  result  of  the  anesthesia,  which  should 
be  recognized  and  so  far  as  possible  alleviated.  Sometimes  he  will 
complain  of  a  soreness  about  the  angle  of  the  jaw,  with  pain  on  opening 
the  mouth.  This  is  due  to  the  holding  forward  of  the  jaw  which  the 
anesthetist  has  found  necessary,  lest  otherwise  the  tongue  would  fall 
back  against  the  glottis  and  impede  or  obstruct  respiration.  A  flabby 
state  of  the  tongue  under  anesthesia  is  not  uncommonly  found,  especially 
in  persons  without  teeth;  sometimes  holding  the  head  turned  to  one 
side  will  prevent  its  sliding  backward.  The  soreness  usually  wears 
off  in  two  or  three  days;  if  severe,  a  menthol  pencil  may  be  applied 
over  the  articulation  or  chloroform  liniment  rubbed  in. 

Sore  Tongue. — -If  it  has  been  found  necessary  to  resort  to  the 
use  of  the  tongue-forceps,  or  to  sew  a  silk  thread  through  the  tip  of 
the  tongue,  in  order  to  hold  it  forvi^ard,  especially  if  Laborde's  rhythmic 
traction  has  been  performed,  the  tongue  may  become  sore  and  painful. 
The  forceps  which  induces  the  least  traumatism  to  the  tongue  is  the 
Carmalt,  which  has  a  single  prong  (Fig.  ii,  p.  30).  Forceps  which 
depends  upon  pressure  for  its  grip,  and  especially  hemostatic  forceps  used 
in  an  emergency,  may  cause  some  laceration  and  superficial  slough.  A 
tongue  may  be  rather  severely  lacerated  by  being  caught  betw'een  the 
teeth  and  bitten  in  the  state  of  spasmodic  contraction  of  the  jaw  muscles, 
which  is  apt  to  precede  attempts  at  vomiting  during  recovery  from 
ether.  Ordinarily  rinsing  out  the  mouth  with  a  warm  mild  antiseptic, 
as  boric  acid  or  Dobell's  solution,  will  give  relief  and  conduce  to  the 
comfort  of  the  patient.  If  there  is  any  slough  or  ulceration,  a  10  per  cent. 
solution  of  silver  nitrate  should  be  applied  and  a  potassium  chlorid 
mouth-wash  used. 

Sore  Chest. — Not  infrequently  a  patient  will  call  the  doctor's 
attention  to  a  soreness  in  the  lower  chest,  or  a  pain  in  the  sternum  and 
lower  ribs  which  is  aggravated  by  deep  inspiration.  This  may  be  due 
to  violent  retching  during  recovery  or  to  artificial  respiration  resorted 

164 


CONJUNCTIVITIS  165 

to  during  or  after  the  operation.  This  soreness  is  Hkely  to  persist 
only  two  or  three  days,  and  some  rehef  may  usually  be  obtained  by 
rubbing  with  liniment.  If  the  pain  is  severe,  a  tight  chest  swathe  may 
be  applied.  If  a  patient  has  been  hung  up  in  the  Trendelenburg  posture 
during  a  long  operation,  she  may  complain  later  of  pains  under  the 
knees  and  in  the  calves,  and  there  is  probably  an  increased  likelihood 
of  a  phlebitis  of  the  calf  occurring  under  these  circumstances.  If  her 
weight  has  been  resting  against  metallic  shoulder  supports,  she  will 
probably  experience  some  soreness  in  her  arms  and  shoulders. 

Burns  may  be  the  result  of  using  hot-water  bags  or  bottles  w^ithout 
adequate  protection  of  the  skin  or  using  water  for  washing  or  irrigation 
which  is  too  hot.  These  are  sometimes  severe  and  may  be  serious. 
Burns  of  slight  degree  may  occur  about  the  mouth  and  face  from 
the  action  of  liquid  chloroform  or  ether.  It  is  more  likely  to  occur 
if  the  drop  method  is  used,  and,  to  prevent  it,  the  face  should  be 
smeared  with  vaselin  before  the  anesthesia  is  begun,  and  the  ether 
should  be  spread  over  a  sufficiently  large  evaporating  surface  and  not 
allowed  to  drop  on  one  spot.^ 

Paralysis  may  appear  as  a  result  of  pressure  or  of  a  strained  posi- 
tion of  the  arms  or  legs  during  operation.  The  commonest  form  is 
musculospiral  paralysis,  which  occurs  if  an  arm  is  left  hanging  without 
support  over  the  edge  of  the  operating  table  (Fig.  13,  p.  31).  There 
may  be  paralysis  of  the  entire  arm  from  pressure  on  the  brachial  plexus, ' 
if  the  patient  is  allowed  to  lie  on  his  arm  during  operations  on  the  kidney 
performed  in  the  lateral  posture.  These  paralyses  are  usually  ephem- 
eral, passing  off  in  at  most  a  few  weeks;  sometimes  they  persist  for 
months  after  the  operation.  Strychnin,  electricity,  and  massage  are 
indicated  in  the  treatment.^ 

Conjunctivitis  should  not  occur  with  an  experienced  etherizer 
under  ordinary  circumstances.  It  is  the  result  of  strong  ether  vapor 
or  of  the  ether  itself  getting  into  the  eye.  If  the  eyes  are  held  closed, 
there  will  be  no  chance  for  the  vapor  to  cause  irritation;  a  drop  of 
ether  may  accidentally  be  spilled  if  the  patient  is  unusually  refractive 
in  going  under,  or  in  the  flurry  of  vomiting  or  artificial  respiration  on 

1  Van  Kaathoven,  Twenty-five  Hundred  Cases  of  Gas-Ether  Anesthesia  without  Com- 
plication, Ann.  Surg.,  1908,  xl\iii,  435. 

2  A.  E.  Haisted  (Anesthesia .  Paralysis,  Wisconsin  Med.  Jour.,  1908,  vi,  511)  gives  a 
series  of  cases  showing  various  varieties  of  paralysis  following  and  dependent  upon  the 
administration  of  a  general  anesthetic.  He  describes  two  forms,  peripheral  and  central. 
The  peripheral  may  be  averted  by  proper  handling  through  narcosis.  The  central  cannot 
be  prevented,  though  its  danger  may  be  avoided  by  limiting  the  quantity  of  anesthetic 
and  by  a  preliminary  hypodermic  of  morphin  in  ether  anesthesia  to  control  excitement. 


1 66  SEQUELS   OF   THE   ANESTHESIA 

the  table.  If  there  is  any  suspicion  in  the  mind  of  the  anesthetist  that 
ether  may  have  come  in  contact  with  the  eye,  he  should,  as  a  prophylactic 
measure,  irrigate  the  eye  thoroughly  at  once,  if  possible,  with  warm 
water,  normal  saline,  or  boric  solution,  whichever  is  at  hand.  This  is 
done  by  dipping  a  gauze  sponge  into  the  solution,  and,  holding  it  a  few 
inches  above  the  eye,  allowing  the  solution  to  drip  gently  on  the  con- 
junctiva. If,  in  the  neglect  of,  or  in  spite  of,  this  precaution,  the  eye 
on  the  second  day  begins  to  look  injected  and  feel  irritated,  a  drop 
of  a  solution  containing  one  grain  each  of  zinc  sulphate  and  cocain 
hydrochlorid  to  the  ounce  of  sterile  water  may  be  instilled,  warm,  into 
the  eye  every  few  hours,  and  boric  acid  irrigation  carried  on  twice  a 
day  so  long  as  any  excretion  appears. 

Postanesthetic  Pneumonia. — The  occurrence  of  pneumonia 
and  other  lung  complications  after  anesthetization  has  been  a  moot 
point  in  surgery.  There  is  no  question  but  that  lung  complica- 
tions arise  as  a  direct  or  indirect  result  of  the  use  of  a  general  anesthetic, 
especially  after  capital  operations,  although  some  of  the  cases  reported 
are  undoubtedly  due  to  the  coincident  action  of  other  causes.  When 
they  do  occur,  they  are  troublesome  because  of  the  discomfort  and  dis- 
tress to  which  they  give  rise,  and  because  of  the  possibilities  of  danger 
which  arise  in  reference  to  the  effect  of  the  strain  of  coughing  on  liga- 
tures and  sutures;  they  are  extremely  likely  to  become  serious,  par- 
ticularly in  elderly  and  debilitated  persons,  because  they  come  at  a 
time  when  the  patient's  condition  is  already  below  par  and  his  resistance 
lowered.  The  occurrence  seems  to  increase  directly  with  the  length  of 
anesthesia  and  inversely  to  the  protection  of  the  patient.  This  latter 
includes  the  maintenance  of  a  proper  temperature  in  the  operating 
room,  keeping  the  patient  dry,  and  protecting  from  draughts  during 
recovery.  In  private  practice  the  occurrence  is  less  than  in  public 
hospitals,  where  the  patient  is  often  trundled  inconsiderately  out  of  a 
warm  operating  room  along  a  corridor  for  some  distance  to  the  recovery 
ward. 

It  is  generally  stated  that  the  liability  to  lung  complications  is  less 
after  chloroform  than  after  ether.  Upon  this  statement  is  based  the 
assertion  that  ether  should  not  be  the  anesthetic  of  choice  where  there 
is  present  any  disease  of  the  lungs  or  air-passages,  any  condition  which 
results  by  pressure  or  otherwise  in  a  lessening  of  the  lumen  of  the  trachea 
or  bronchi,  or  in  any  case  where  the  Trendelenburg  posture  will  have 
to  be  assumed  and  maintained  for  a  considerable  length  of  time,  the 
pressure  of  the  intestines  against  the  diaphragm  interfering  with  the 
free  action  of  this  organ.     Ether  acts  as  a  local  irritant  in  exciting  a 


POSTANESTHETIC   PNEUMONIA  1 67 

stimulating  effect  upon  the  glands  of  the  bronchi  so  that  the  secretion 
of  mucus  is  increased.  The  secretion  may  be  so  considerable  as 
effectively  to  block  some  of  the  small  bronchioles.  The  irritant  action 
of  the  ether  may  set  up  a  bronchitis  or  even  a  pneumonia.  The  irritat- 
ing effects  are  less  likely  to  occur  if  a  dilute  vapor  is  used  and  if  the 
ether  is  fresh  and  pure,  for  ether  decomposes  if  allowed  to  stand  in  con- 
tact with  air  in  a  warm  or  light  place.  Chloroform  may  prove  equally 
irritant  if  it  is  kept  in  a  bottle  containing  air  and  exposed  to  the  light. 
Chloroform  vapors,  moreover,  are  decomposed  by  an  open  flame  into 
chlorin  and  carbon  compounds,  which  are  highly  irritating  when  in- 
spired. The  prolonged  use  of  chloroform  in  a  poorly  ventilated  operat- 
ing room  lighted  by  gas  may  induce  serious  respiratory  conditions  in 
the  surgeon  and  attendants  as  well  as  the  patient. 

Of  all  the  respiratory  complications,  bronchitis  is  the  most  frequent. 
It  may  be  due  to  the  lighting  up,  under  the  local  irritant  effect  of  the 
ether,  of  a  previously  existing  or  a  chronic  bronchitis.  There  can  be 
no  doubt,  however,  that  it  sometimes  arises  as  a  direct  result  of  the 
inhalation  of  considerable  volumes  of  cold  and  concentrated  ether  vapor, 
and  from  undue  exposure  or  chilling  of  the  body  surface  in  persons 
not  strongly  resistant,  as  a  result  of  age  or  general  condition.  It  may, 
by  extension,  develop  into  a  bronchopneumonia.  It  may  be  borne  in 
mind  that  it  is  particularly  improper  to  leave  the  patient  wrapped  in 
clothes  which  have  become  wet  with  irrigating  solutions,  for,  because 
of  evaporation,  the  loss  of  heat  is  greater  in  wet  clothes  than  in  no 
clothes  at  all.  - 

Pulmonary  edemu  has  been  reported,^  but  this  must  be  considered 
as  dependent  on  cardiac  weakness,  associated,  perhaps,  with  the  fact  that 
under  the  influence  of  ether  the  pulmonary  vessels  lose  their  tone  and 
dilate  and  thus  become  more  pervious.^  The  postoperative  occurrence 
of  pleurisy  has  been  rarely  noted. 

The  proportion  of  pneumonia  as  reported  by  various  observers  ranges 
from  3  in  2400  cases  in  general  (Crouch  and  Corner,  quoted  by  Mum- 
mery) to  143  out  of  1787  laparotomies.^  The  discrepancy  between  8 
per  cent,  and  one-eighth  of  i  per  cent,  is  to  be  explained  by  stating  that 
the  English  cases  were  general  cases,  were  etherized  by  trained  anes- 
thetists, and  that  all  cases  of  dung  complication  not  evidently  due  to 
the  ether  were  not  admitted.  There  seems,  however,  to  be  general 
concurrence  on  the  rarity  of  the  lobar  type.     Hewitt  (Anesthetics)  and 

^  Nauwerck,  Deutsch.  med.  Woch.,  1895,  xxi,  121. 
^  Lindemann,  Centralb.  f.  allg.  Path.,  1898,  ix,  442. 
■    ^  Henle,  Verhandl.  d.  Deutsch.  Gesellsch.  f.  Chir.,  190T,  xxx,  240. 


1 68  SEQUELS    OF    THE   ANESTHESIA 

W.  H.  Prescott  ^  go  so  far  as  to  say  that  if  it  occurs  the  ether  cannot  be 
held  alone  responsible,  and  that  it  must  be  regarded  as  a  coincidence. 
J.  C.  Munro^  reports  that  in  looo  laparotomies  34  patients  showed 
signs  and  symptoms  pointing  to  trouble  in  the  respiratory  organs.  Of 
these,  all  but  11  could  be  excluded  as  being  not  postoperative  pulmonary 
complications.  Of  these  n,  4  proved  fatal,  a  mortality  of  ^  of  i  per 
cent.  This  compares  favorably  with  the  reported  foreign  mortality 
of  3  to  5  per  cent.,  and  proves  the  advantage  of  careful  routine  methods 
in  preparation,  etherization,  and  after-care.  Practically  all  these 
cases,  excepting  the  femoral  hernias,  were  set  upright  in  bed  at  once, 
or  within  a  few  hours,  after  operation.  The  majority  were  out  of  bed 
in  forty-eight  hours  and  were  given  as  liberal  a  diet  as  they  could  be 
persuaded  to  take.  All  were  encouraged  to  move  the  body  and  ex- 
tremities, and  they  were  given  water  liberally  to  keep  down  thirst  and 
to  prevent  the  dirty  dry  mouth  that  comes  with  the  lack  of  moisture. 

The  first  sign  of  pneumonia  generally  appears  in  the  form  of  a  rise 
in  temperature  to  101°  or  over  during  the  second  twenty-four  hours 
after  operation.  The  patient  generally  suffers  severely,  and  in  some 
w^ays  the  condition  resembles  lobar  pneumonia,  although  there  is  neither 
the  profound  toxemia  nor  the  high  temperatures  of  the  latter  form.  The 
treatment  should  be  the  ordinary  treatment  of  pneumonia  in  the  adult. 
The  course  is  usually  short  and  acute.  Inasmuch  as  the '  patient  is 
already  in  a  state  of  more  or  less  exhaustion  as  a  result  of  the  operation, 
there  should  be  no  hesitation  in  exhibiting  cardiac  stimulation  from 
the  inception  of  the  disease  without  w^aiting  for  evidences  of  cardiac 
weakness  to  present  themselves. 

To  recapitulate  (John  Bapst  Blake),  all  postoperative  pneumonia 
is  bronchopneumonia;  the  exceptions  to  this  are  so  rare  that  lobar 
pneumonia  after  operation  is  to  be  considered  as  a  coincidence  only. 
The  cause  of  postoperative  pneumonia  is  usually  multiple :  (i)  Imper- 
fect etherization,  due  usually  to  carelessness  or  ignorance,  occasionally 
to  unusual  difficulties  inherent  in  the  case  itself;  (2)  neglect  or  insuf- 
ficient preoperative  preparation  of  the  teeth  and  mouth;  (3)  insufficient 
covering  of  the  patient  on  the  table  and  during  transfer  after  the  opera- 
tion; this  lack  includes  lack  of  proper  heat  in  the  operating  room; 
(4)  the  Trendelenburg  position  in  too  extreme  a  degree  or  for  too  long 
a  time;  (5)  too  little  fresh  air  and  too  little  oxygen;  (6)  neglect  of  the 
precaution  of  propping  the  patient  up  in  bed  at  the  earliest  possible  time 

^  Boston  Med.  and  Surg.  Jour.,  1895,  cxxxii,  304. 

^  A  Brief  Consideration  of  the  Pulmonary  Complications  of  One  Thousand  Laparot- 
omies, Jour.  Amer.  Med.  Assoc,  1909,  liii,  425. 


POSTANESTHETIC    NEPHRITIS  1 69 

and  turning  him  on  his  side  on  the  afternoon  of  operation  if  possible; 
(7)  careless  exposure  of  the  shoulders  to  draughts  and  to  open  windows 
soon  after  the  operation.  The  causes  are  almost  always  preventable. 
The  frequency  of  the  occurrence  is  from  2  to  5  per  cent,  in  all  capital 
operations,  and  is,  therefore,  much  larger  than  is  ordinarily  stated; 
the  proportion  actually  due  to  the  irritating  or  chilling  effect  of  the  ether 
vapor  on  the  lungs  alone  is  probably  small.  It  is  a  serious  complica- 
tion and  is  the  actual  cause  of  a  large  percentage  of  the  fatalities  in  old 
and  debilitated  cases.^ 

Nephritis. — After  anesthesia  the  urinary  secretion  is  much  lessened 
and  continues  abnormally  low,  though  gradually  increasing  for  a  week 
or  ten  days.  Thus,  Penrose  -  showed  that  after  laparotomy  the  average 
secretion  in  in  cases  during  the  first  t^venty-four  hours  was  13.4  oz., 
or  about  one-quarter  the  normal  quantity.  During  the  second  twenty- 
four  hours  it  was  14.6  oz.  and  the  third  19.6.  Grieg  Smith  ^  observed 
128  cases  and  got  similar  though  higher  results.  The  diminution, 
however,  as  shown  by  Buxton  and  Le\%*  is  chiefly  in  the  water  rather 
than  in  the  solids,  and  depends  largely  on  the  lessened  amount  of  fluids 

^  Chapman,  Postoperative  Pneumonia,  with  Experiments  upon  its  Pathogen)-,  Ann. 
Surg.,  1904,  xxxix,  700. 

Prescott,  in  reviewing  40,000  etherizations  at  the  Massachusetts  General  Hospital,  found 
but  3  cases.  Silk  reports  13  in  5000  surgical  cases,  and  Anders,  in  a  review  of  12,842  surgical 
cases,  found  30.  Kelley  has  seen  8  cases  in  1800  administrations.  Chapman  presents  an 
account  of  experiments  upon  the  irritant  effects  of  ether,  and  states  that  surgical  pneumonia 
may  be  divided  into  two  classes:  first,  one  in  which  infectious  particles  are  drawn  into  the 
lungs  by  the  violent  inspiratory  efforts  incident  to  anesthesia;  the  other,  in  which  organisms 
of  particular  virulence  find  soil  suitable  to  their  growth  and  multiplication,  but  he  con- 
cludes that  ether  has  a  distinct  irritant  effect  upon  the  lungs,  causing  a  swelling  of  alveoli 
and  the  congestion  of  the  alveolar  tissue,  and  even  intra-alveolar  hemorrhage,  which  in- 
crease with  the  length  of  etherization  and  with  the  amount  of  forcing  or  crowding  of  the 
ether. 

V.  Lichtenberg  and  Miiller  (Verhulter  der  Lungen  und  des  Herzens  nach  abdom- 
inalen  Eingriffen,  Miinch.  med.  Woch.,  igog,  Ivi,  435)  show  complications  on  the 
part  of  the  lungs  to  be  responsible  for  fatalities  after  operation  upon  the  stomach 
in  29  per  cent.,  after  operation  on  the  biliary  passages  in  15  per  cent.,  after  herni- 
otomy in  25  per  cent.,  after  operation  for  goiter  in  44  per  cent.,  in  gynecologic  opera- 
tions in  20  per  cent.  Postoperative  complications  on  the  part  of  the  lungs  are  far  more 
common  than  generally  recognized.  Many  a  slight  increase  in  temperature  in  the  first 
few  days  after  aseptic  operations  is  the  result  of  pulmonary  complications.  They  may 
disappear  entirely  in  a  few  days  without  inconvenience,  but  they  may  pro^dde  the  soil  upon 
which  pneumonia  develops.  The  method  of  anesthesia,  he  finds,  has  no  influence  upon 
the  development  of  postoperative  complications,  which  confirms  the  extreme  rarity  of 
pneumonia  due  truly  to  the  inhaled  anesthetic.  An  embolic  process  is  evidently  responsible 
for  the  postoperative  pulmonary  complications  in  the  vast  majority  of  cases,  but  the  hypo- 
static organ  must  be  excepted  in  a  few  isolated  cases. 

^  Ann.  Surg.,  1895,  xxvi,  184.  ^  Abdominal  Surgery,  1896,  137. 

^  Brit.  Med.  Jour.,  1900,  i,  833. 


170  SEQUELS    OF    THE    ANESTHESIA 

taken  and  retained,  purgation,  sweating,  etc.  Cases  of  complete  sup- 
pression of  urine  and  death  have  been  reported  as  due  to  the  anesthetic 
They  are  rare,  although  the  secretion  may  become  very  slight  in  case 
of  severe  shock  or  hemorrhage,  and  ordinarily  in  postoperative  anuria 
some  other  cause  may  legitimately  be  sought,  such  as  tied,  cut,  or  kinked 
ureters,  or  Bright's  disease.  Good  observers  have  reported  cases  where 
ether  in  elderly  persons  with  Bright's  disease  or  arteriosclerotic  kidneys 
has  been  followed  by  gradual  suppression  and  death,  with  no  cause 
but  the  preexisting  nephritis  demonstrable  at  autopsy.  Primary  acute 
nephritis  occurring  after  anesthesia  is  extremely  rare,  if  it  occurs  at  all. 

In  spite  of  this,  abnormal  urinary  constituents  are  found  after  ether  in 
a  large  percentage  of  all  cases — practically  in  one-quarter  to  one-third — 
immediately  after  operation;  there  are  abundant  casts,  hyaline,  fine 
and  coarse  granular  and  epithelial,  and,  somewhat  less  frequently,  al- 
bumin. The  occurrence  after  chloroform  anesthesia  is  considerably 
less,  although  chloroform  undoubtedly  also  acts  as  an  irritant  during 
elimination.  These  abnormal  elements  will  have  usually  completely 
disappeared  in  from  eighteen  to  twenty-four  hours,  but  they  may  last 
forty-eight  hours  or  longer  in  septic  cases  or  cases  doing  badly,  in  case 
of  complication  arising,  such  as  pneumonia,  or  in  the  case  of  a  previously 
existing  nephritis. 

The  cause  of  the  "shower"  of  casts  which  is  so  likely  to  follow  on 
etherization  may  be  the  renal  congestion  resulting  from  the  chilling  of 
the  relaxed  surface  of  the  body,  renal  irritation  from  the  anesthetic  or 
toxic  or  septic  products,  or  the  concentrated  state  of  the  urine.  If 
albuminuria  or  cylindruria  exists  before  the  operation,  it  is  usually 
temporarily  increased  by  ether,  but  more  frequently  by  chloroform. 
It  is  the  generally  accepted  opinion  that  ether  does  little  or  no  lasting 
harm  to  the  kidneys,  even  though  renal  disease  is  already  present. 
Chloroform  bears  a  bad  reputation  in  nephritis,  and  if  this  exists,  ether 
should  be  given  the  preference.  Chloroform  may  bring  about  fatty 
degeneration  of  the  kidneys,  just  as  it  sometimes  causes  fatty  liver  and 
heart.^ 

^  M.  Hirsch  (Einwirkung  der  allgemeinen  Narkose  und  der  Spinalanalgesie  auf 
die  Nieren  und  ihr  Sekret,  Centralb.  f.  d.  Grenzg.  der  Med.  u.  Chir.,  1908,  xi,  929) 
analyzes  207  articles.  The  effect  of  chloroform  and  ether  on  the  kidneys  is  merely  one 
manifestation  of  a  general  intoxication  of  the  system  from  the  drug.  Chloroform  or  ether 
can  be  used  with  the  ordinary  technique  if  the  kidneys  are  known  to  be  sound,  but  if  the 
kidneys  are  pathologic,  chloroform  is  absolutely  contra-indicated.  Under  all  conditions  the 
amount  of  the  anesthetic  used  should  be  the  smallest  possible.  Much  less  of  an  anes- 
thetic is  used  when  administered  drop  by  drop  and  the  limit  of  tolerance  is  more  rapidly 
reached.  Loss  ot  blood  should  be  combated  in  every  possible  way,  as  this  favors  the 
degenerative  action  of  the  anesthetic  and  contributes  to  the  possibility  of  chloroform  in- 


POSTANESTHETIC    NEPHRITIS  171 

Treatment. — As  a  prophylactic  measure,  when  nephritis  exists 
ether  should  always  be  used,  and  the  least  possible  quantity  of  anes- 
thetic should  be  employed.  Carefully  avoid  dampness,  draughts,  and 
exposure.  If  suppression  threatens,  give  water  by  the  mouth,  subcu- 
taneously,  and  by  rectum.  Promote  sweating  by  hot  packs  and  hot- 
air  baths.  In  case  of  eniergency  do  venesection,  and  after  bleeding 
give  salt  solution  intravenously.  In  any  case  promote  urinary  and 
bowel  secretion.  Give  digitahs  and  potassium  acetate  or  citrate.  Com- 
bat nephritis  in  septic  cases. 

toxication.  It  is  also  important  to  refrain  from  administering  a  general  anesthetic  several 
times  to  the  same  patient  within  a  short  interval.  If  the  chloroform  intoxication  is  super- 
imposed on  a  preceding  similar  intoxication  before  the  kidneys  have  had  time  to  recuperate 
completely,  there  is  liable  to  be  serious  trouble.  The  danger  in  the  second  anesthesia  is 
far  more  imminent  than  in  the  first.  The  interval  should  be  at  least  a  week  and  the  second 
anesthesia  should  never  be  attempted  until  the  urine  is  free  from  albumin. 


CHAPTER  XIX 

ACETONEMIA;  ACETONURIA;  AQDOSIS;  ACID  INTOXI- 
CATION; FATTY  DEGENERATION  OF  THE  LIVER 

Soon  after  chloroform  came  into  general  use  as  an  anesthetic  it  was 
noted  that  in  some  cases,  especially  in  children  under  fifteen  years  of 
age,  a  profound  intoxication,  characterized  often  by  incessant  vomiting, 
would  make  its  appearance  from  tv^'O  to  five  days  after  the  anesthetic. 
This  was  called  delayed  chloroform  poisoning.  In  some  cases  sugar 
and  acetone  were  found  in  the  urine,  and  in  these  it  was  supposed  that 
the  S)arLptoms  were  due  to  an  unrecognized  diabetes,  especially  as  the 
patients  frequently  died  in  coma.  In  other  cases,  in  which  post-mortem 
examinations  were  made,  nothing  was  found  to  account  for  death  except 
a  more  or  less  general  infiltration  of  the  heart,  kidneys,  voluntary  muscles, 
and  liver  with  fat;  the  condition  was  usually  especially  pronounced  in 
the  liver,  so  that  it  resembled  the  liver  of  phosphorus-poisoning,  and 
there  were  sometimes  necrosis  and  contraction,  as  in  acute  yellow  atrophy. 

As  more  attention  began  to  be  paid  to  this  condition,  it  was  found 
that  the  urine  in  practically  all  the  cases  showing  this  symptom-complex 
exhibited  an  excess  of  acetone.  It  was  then  felt  that  the  symptoms 
were  due  to  an  acidosis  or  acid  intoxication  as  a  result  of  some  acute 
disturbance  of  metabolism. 

Acetone  was  first  discovered  in  the  urine  in  1857  by  Fetters  in  a  case 
of  diabetes.  Further  investigation  demonstrated  (^Miiller)  that  it  is  to  be 
found  often  in  minute  quantities  in  the  urine  and  blood  of  normal  in- 
di\iduals,  and  in  increased  amount  if  the  patient  is  subjected  to  tem- 
porary starvation.  Then  it  was  determined  that  the  amount  of  acetone 
in  the  urine  became  regularly  increased  after  narcosis,^  and  it  was  at 
first  believed  that  this  was  due  to  opening  the  peritoneal  ca^^ty  or  to 
the  use  of  corrosive  sublimate.  It  was  found  that  this  postnarcotic 
excess  lasts  from  a  few  hours  to  several  days  after  operation,"  and  that 
if  acetonuria  is  present  before  the  operation,  narcosis  increases  it,^ 
J.  A.  Kelly  *  reported   that  out  of  400  postoperative  cases  observed 

^  Conti,  Vratsch,  Dec.  7,  1893;  Grevan,  Ueber  Aceturie  nach  der  Narkose,  Bonn,  1895. 
2  E.  Becker,  Arch.  gen.  path.  Anat.  u.  Phys.,  1895,  cxl,  i. 
^Abram,  Jour.  Path,  and  Bact.,  1896,  iii,  430. 
*Ann.  Surg.,  1905,  xli,  161. 
172 


ACETONURIA  1 73 

at  the  Boston  City  Hospital  46  showed  acetone  and  symptoms  of  in- 
toxication, with  6  deaths.  J.  C.  Hubbard  ^  concluded,  after  an  ex- 
amination of  145  postoperative  cases  at  the  Boston  City  Hospital,  that 
the  occurrence  of  acetone  after  operation  was  frequent.  H.  Baldwin  ^ 
found  acetone  in  the  urine  of  64  out  of  78  operative  cases  the  day 
after  operation,  and  Telford  and  J.  L.  Falconer^  reported  3  fatal  cases 
after  chloroform,  and  symptoms  from  the  presence  of  acetone  in  34  out 
of  118  postanesthetic  cases.  A.  G.  Rice*  reported  that  an  excess  of 
acetone  was  found  in  90  per  cent,  of  202  cases  after  etherization  at 
the  Boston  City  Hospital  in  which  no  sugar  w^as  present  before  opera- 
tion. It  appeared  most  commonly  on  the  second  and  third  day,  and 
after  the  fourth  day  it  was  rare.  Of  these,  10  per  cent,  showed  symp- 
toms suggestive  of  acid  intoxication.  Only  2  cases,  however,  were 
severely  sick,  and  of  these,  i  died.  J.  W.  Sever  ^  found  that  after  681 
etherizations  at  the  Children's  Hospital  acetone  occurred  in  the  urine 
of  662  and  symptoms  of  acid  intoxication  in  60.  It  appeared,  as  a 
rule,  at  once  after  the  operation  and  lasted  on  the  average  three  days. 
Death  occurred  in  16  cases,  in  7  of  which  the  acid  intoxication  was 
probably  the  determining  factor.^ 

The  condition  began  to  assume  clinical  importance  with  the  publica- 
tion of  fatal  postanesthetic  cases  apparently  depending  on  a  systemic 
acetone  intoxication.  Among  others,  Brewer '' reported  i  fatal  case; 
Brackett,  Stone,  and  Low  ^  reported  7  cases  from  the  Children's  Hospital, 
with  3  fatalities.  R.  Campbell  ^  reported  3  fatal  cases  after  chloroform, 
and  A.  N.  McArthur^"  reported  one  fatality  after  chloroform.  Bevan 
and  Favill"  collected  from  the  literature  29  undoubted  cases  of  this  con- 

^  Boston  Med.  and  Surg.  Jour.,  1905,  clii,  744. 

^  Jour,  of  Biol.  Chem.,  1906,  i,  239. 

^Lancet,  1906,  ii,  1341. 

*  Some  Observations  on  Acetonuria,  Boston  Med.  and  Surg.  Jour.,  1908,  clix,  47. 

^  Acetone,  Its  Occurrence  in  Orthopedic  and  Surgical  Cases,  Amer.  Jour,  of  Ortho. 
Surg.,  1909,  vi,  408. 

^Ladd  and  Osgood  ("Gauze  Ether,"  or  a  Modified  Drop  Method  with  its  Effect 
Upon  Acetonuria,  Ann.  Surg.,  1907,  xlvi,  460)  found  that  after  120  cases  of  etherization 
by  the  cone  method  at  the  Boston  City  Hospital  106  showed  acetone,  88J  per  cent.  After 
the  drop  method  of  anesthesia  they  found  acetone  in  only  26  per  cent,  of  222  cases. 

'  Fatal  Acetonemia  Following  an  Operation  for  Acute  Appendicitis,  Ann.  Surg.,  1902, 
xxxvi,  481. 

^Aciduria  (Acetonuria)  Associated  with  Death  after  Anesthesia,  Boston  Med.  and 
Surg.  Jour.,  1904,  cli,  2. 

^  Acid  Intoxication  Following  General  Anesthesia,  Medical  Press  and  Circular,  1907, 
Ixxxiii,  198. 

***  Acidosis,  Intercolonial  Med.  Jour.,  Melbourne,  1907,  xii,  434. 

^^  Acid  Intoxication  and  Late  Poisonous  Effects  of  Anesthetics,  Jour.  Amer.  Med. 
Assoc,  1905,  xlv,  691,  757. 


174  ACETONEMIA — FATTY   DEGENERATION    OE    THE    LIVER 

dition,  in  addition  to  i  of  their  own,  of  which  28  died.  They  called 
attention  to  the  liver  as  the  probable  source  of  the  toxemia,  and  to  the 
similarity  which  existed  betT\^een  this  condition  and  acute  yellow  atrophy, 
phosphorus-poisoning,  puerperal  eclampsia,  and  diabetic  coma. 

It  is  at  present  generally  assumed  that  fat  is  the  principal  source  of 
the  acetone  bodies,  and  that  their  place  of  formation  is  chiefly  in  the 
liver.^  Acidosis  is  not  to  be  considered,  however,  as  the  result  of  an 
excessive  consumption  of  fat,  but  it  depends  usually  upon  the  absence 
of  carbohydrates.^  It  is  caused  or  accompanied  by  some  marked 
change  in  the  fat  metabolism  of  the  body  and,  accordingly,  L.  Guthrie  ' 
infers  that  acid  intoxication  is  liable  to  occur  in  all  cases  in  which  the 
liver  is  excessively  fatty.  Twenty  of  the  24  cases  in  the  series  of 
Bevan  and  Favill,  which  came  to  autopsy,  showed  fatty  changes  in  the 
liver. 

The  conditions  in  which  the  existence  of  a  superfatted  liver  may  be 
suspected,  which  should  be  avoided  in  general  anesthesia,  are  numer- 
ous and  include  diabetes,  deprivation  of  carbohydrates  (starvation), 
sepsis  (acute  and  chronic),  specific  infections,  as  diphtheria  and  pneu- 
monia, and  poisoning  with  phosphorus  and  chloroform.  The  work 
of  the  liver  is  to  take  up  the  fat  from  other  parts  of  the  body  and 
bring  about  certain  changes  in  it,  the  result  of  which  is  to  make  this 
material  available  for  the  use  of  the  organs  in  which  its  potential  energy 
is  required.  Too  active  a  mobilization  of  stored  fat,  or  too  little  activity 
in  dealing  with  it  on  the  part  of  the  liver,  will  result  in  an  accumulation 
of  the  unfinished  product  in  that  organ.  A  fatty  liver  is  then  the  result.* 
The  condition  implies  a  defective  metabolism  and  oxidation,  and  the 
further  perversion  of  metabolism  and  oxidation  by  a  general  anesthetic 
may  give  rise  to  a  fatal  toxemia,  accompanied  by  a  general  breakdown 
of  all  hepatic  functions  and  fatty  acid  intoxication,  which  in  extreme 
cases  may  go  on  to  an  acute  atrophy. 

The  action  of  chloroform,  particularly  upon  the  liver,  was  noted 
some  years  ago  without  being  clearly  understood.  Recently  it  has  been 
shown  in  dogs  ^  that  necrosis  of  the  liver  occurs  after  a  single  chloroform 
anesthesia  of  one  hour,  and  intense  fatty  changes  when  chloroform  is 

^  E.  H.  Goodman,  Recent  Advances  in  Our  Knowledge  of  the  Underlying  Chemical 
Principles  of  Diabetic  Acidosis,  Arch.  Int.  M«d.,  1908,  i,  397. 

"  Bainbridge,  Pathology  of  Acid  Intoxication,  Lancet,  1908,  i,  911. 

^  Fatty  Acid  Intoxication,  Brit.-  Med.  Jour.,  190S,  ii,  1158. 

■*  Leathes,  The  Functions  of  the  Liver  in  Relation  to  the  Metabolism  of  Fats,  Lancet, 
1909,  i,  593. 

^  Rowland  and  Richards,  The  Experimental  Study  of  the  Pathology  and  Metabolism 
of  Delayed  Chloroform  Poisoning,  Ann.  Surg.,  1909,  xlix,  419. 


FATTY    LIVER    FROM    CHLOROFORM  1 75 

given  for  a  much  shorter  period.  K.  Reicher  ^  shows  that  the  important 
liquids  and  fats  are  expelled  by  the  cells  under  the  influence  of  the 
anesthetic.  H.  G.  Wells-  divides  the  cases  of  delayed  chloroform- 
poisoning  into  two  classes.  In  one,  chiefly  children,  the  s}Tnptoms  are 
those  of  acidemia  or  acetonuria  without  jaundice.  In  these  cases  the 
changes  of  the  liver  are  not  very  marked,  consisting  chiefly  of  fatty 
degeneration  about  the  periphery  of  the  liver  lobules.  The  other  type 
is  observed  chiefly  in  young  adults,  and  clinically  is  marked  by  a 
profound  jaundice,  hemorrhage,  and  the  usual  symptom-complex  of  a 
rapidly  fatal  acute  yellow  atrophy,  the  liver  being  reduced  in  size, 
flabby,  yellow,  and  showing  microscopically  an  extreme  degree  of 
necrosis,  beginning  in  the  center  of  the  lobule,  with  more  or  less  fatty 
peripheral  degeneration.  There  are  intermediate  cases  which  do  not 
follow  distinctiy  one  or  the  other  of  the  two  types. 

Youth  appears  to  be  an  important  factor  among  predisposing  causes. 
All  the  7  cases  of  Brackett,  Stone,  and  Low  were  in  children;  of  the 
series  of  Bevan  and  Favill,  one-half  the  cases  were  under  ten  years 
and  two-thirds  under  hventy.  K.  Schrack  ^  observed  that  children 
were  frequently  likely  to  exhibit  acetone  in  their  urine,  especially  in 
febrile  affections  and  gastro-intestinal  derangements.  Marpan  and 
Edsail  showed  the  intimate  relationship  of  acetonuria  with  cyclic  vomit- 
ing in  infants.     Hecker*  asserts  that  children  are  especially  liable  to 

^  Chemical  and  Experimental  Studies  of  General  Anesthesia,  Zeitsch.  f.  klin.  Med., 
1908, Ixv,  235. 

^  Wells  (Necrosis  of  the  Liver  After  Chloroform  Anesthesia,  Arch.  Int.  Med.,  1908,  i, 
589)  cites  a  case — male,  nineteen,  appendix  operation.  Prompt  recovery  from  anesthetic, 
good  progress  until  the  third  day,  on  the  morning  of  which  pulse  dropped  to  66,  tem- 
perature being  99-2°.  About  noon  noticed  to  be  acting  irrationally.  Two- hours  later  acute 
mania  developed,  requiring  the  efforts  of  several  persons  to  restrain  him.  Kept  quiet 
under  morphin  until  the  follo-^ing  afternoon,  when  he  became  passive,  l)ing  quietly  on  his 
back,  pulse  increasing  and  becoming  weaker.  Temperature  rising.  Urine  passed  in- 
voluntarily. Then  toxic  convulsions  developed,  followed  by  coma  and  Chejme-Stokes 
respiration.  This  became  more  profound  until  his  death,  which  occurred  five  days  after 
the  operation  and  forty  hours  after  the  first  indication  of  mental  disturbance.  At  the 
time  of  his  death  he  was  markedly  jaundiced.  Autopsy  showed  a  small  Uver  which,  under 
microscopic  examination,  showed  marked  necrosis.  Urine  showed  small  amount  of 
albumin,  distinct  odor  of  acetone,  and  a  marked  reaction  to  diacetic  acid. 

Chloroform  may  cause  death  by  its  destructive  action  on  the  liver.  Its  toxicity  is  due 
to  its  action  as  a  protoplasmic  poison  upon  the  liver-cells,  and  death,  which  is  delayed  for 
several  hours  or  even  days,  results  from  the  perverted  metalx)lism  of  that  organ.  In  this 
condition  of  perverted  metabolism  of  the  liver-cells  the  liver  not  only  fails  to  detoxicate  the 
poisonous  products  of  metabolism  that  are  brought  to  it  by  the  blood-stream,  but  it  under- 
goes a  process  of  self-destruction  or  autoclysis,  and  It  is  the  combined  poisons  of  these  two 
perversions  of  function  which  directly  induce  death. 

^  Fortschritte  der  Med.,  1889,  vii,  746. 

*  Periodic  Acetonemia  in  Children,  Miinch.  med.  Woch.,  1908,  Iv,  1485;  1828. 


176  ACETONEMIA — FATTY  DEGENERATION   OF   THE   LIVER 

exhibit  acetonuria  as  a  result  of  disturbed  metabolism,  and  that  it  is 
probably  due  to  a  defective  development  of  the  function  of  breaking 
down  of  fats.  Brackett,  Stone,  and  Low  believe  that  the  mental  state 
is  to  be  considered  of  importance  in  etiology.  Homesickness,  fright, 
confinement  in  the  hospital,  and  change  of  food  in  children  of  a  high- 
strung  nervous  temperament  may  cooperate  with  the  anesthetic  and  the 
operative  shock  to  induce  an  acute  metabolic  upset.^ 

The  association  of  acetone  with  pregnancy  has  been  noticed.  Acute 
yellow  atrophy  of  the  liver  is  said  also  to  occur  most  frequently  in  preg- 
nant women  and  in  the  latter  half  of  pregnancy.  L.  Knapp  ^  reports 
10  cases  of  acetonuria  in  pregnant  and  parturient  women,  all  of  whom 
gave  birth  to  dead  children,  and  from  this  he  inferred  that  acetonuria 
in  a  pregnant  woman  is  a  sure  sign  of  the  death  of  the  fetus.  H. 
Thompson  ^  reports  a  case  w^ith  the  symptoms  of  acute  yellow  atrophy, 
in  which  the  woman  sank  into  a  stupor,  gave  birth  to  a  macerated 
fetus,  and  died  t^vo  days  later.  Couvelaine  ^  and  Scholten  ^  demon- 
strated a  marked  increase  in  the  acetone  of  the  urine  in  the  large 
majority  of, all  cases  (94  per  cent.)  inamediately  after  labor  and  lasting 
about  three  days.  It  was  most  abundant  after  difficult  and  prolonged 
labors.  J.  B.  Williams  ^  believes  that  some  of  the  cases  of  severe  vomit- 
ing in  pregnancy  are  "  cases  of  toxemic  vomiting  allied  to  yellow  atrophy." 

Authorities  seem  to  agree  unanimously  in  stating  that  chloroform  is  far 
more  apt  to  induce  acid  intoxication  than  is  ether.  Of  Bevan  and  Favill's 
30  cases  ether  was  the  anesthetic  agent  in  only  4.  It  is  generally  assumed 
also  that  the  danger  is  greater  the  more  protracted  is  the  anesthetization, 
although  in  some  cases — probably  extremely  susceptible — a  fatal  ace- 
tonemia has  supervened  on  a  short  anesthesia.  It  is  stated  as  of  par- 
ticular importance,  in  a  patient  at  all  predisposed,  that  if  anesthesia 
has  to  be  repeated  within  three  or  four  days,  and  chloroform  was  given 
the  first  time,  ether  should  be  the  anesthetic  on  the  second  occasion. 
The  nature  of  the  operation  seems  to  be  of  no  importance  in  determining 
the  subsequent  presence  of  acetone,  although  it  is  most  commonly  re- 
ported as  occurring  after  laparotomies.  This  may  be  partly  owing 
to  the  relatively  longer  time  ordinarily  consumed  in  performing  laparot- 

^  V.  Brun  (Clinica  Qiinirgica,  1908,  xvi,  417)  states  that  the  use  of  chloroform  in 
children  is  severe  on  the  liver.  Glycosuria  often  follows  its  administration  and  albumin- 
uria is  also  very  frequent.     He  has  seen  several  deaths,  two  with  fatty  liver. 

^  Centralb.  f.  Gynak.,  1897,  xxi,  417. 

^  Ibid.,  1898,  xxii,  1227. 

*  De  r  Acetonuria  Transitoire  du  travail  de  I'accouchement,  Annalesde  Gyn.  etd'Obst., 
1899,  I,  353. 

"  Ueber  puerperale  Acetonuria,  Beitrage  zur  Geb.  u.  Gyn.,  1900,  iii,  439. 

^  Johns  Hopkins  Hosp.  Bull.,  1906,  x\ii,  71. 


TESTS   FOR   ACETONE   AND   DIACETIC   ACID  177 

omies,  as  compared  with  other  operations,  and  partly  to  the  varying 
degree  of  starvation  to  which  the  patient  who  comes  to  the  operating- 
table  is  usually  subjected  before  an  abdominal  section  is  decided  upon, 
and  which  he  necessarily,  or  by  choice,  undergoes  after  the  operation. 

Other  causes  which  have  been  considered  as  predisposing  to  the 
occurrence  of  acetonuria  after  operation  are  chronic  disease  of  the 
liver  or  kidney;  exhaustion  from  hemorrhage,  starvation,  and  wasting 
diseases,  such  as  carcinoma;  fatty  degenerations,  as  in  the  limbs  after 
infantile  paralysis;  and  lowered  general  vitality,  as  in  sepsis;  diabetes; 
and  in  the  presence  of  a  dead  fetus. 

The  symptoms  of  postoperative  acidosis  are  usually  mild  and  transi- 
tory. At  any  time  from  the  second  day  to  the  fifth  day  after  operation 
the  patient,  who  has  previously  been  doing  perfectly  well,  except  pos- 
sibly for  a  distaste  for  food,  begins  to  vomit.  In  serious  cases  the 
vomiting  soon  becomes  persistent  and  incessant,  and  concurrently  the 
sweetish  fruity  odor  of  acetone  is  to  be  noticed  on  the  breath.  The 
patient  rapidly  develops  a  state  of  collapse  and  looks  desperately  sick, — 
his  face  shows  a  gray  pallor,  his  eyes  are  sunken  and  staring,  and  the 
skin  cold  and  moist;  the  pulse  is  weak  and  rapid;  the  temperature  is 
not  raised.  There  may  be  icterus  in  varying  degree;  it  appears  more  fre- 
quently and  in  a  more  marked  degree  after  chloroform  than  after  ether. 

As  the  condition  progresses  the  patient  becomes  restless,  even  to 
the  point  of  delirium  and  convulsions,  between  the  paroxysms  of 
vomiting;  then  he  will  quiet  down,  and  become  apathetic  and  stuporous. 
Thus  he  w^ill  alternate,  until  the  periods  of  restlessness  become  gradually 
less  pronounced  and  the  stupor  finally  deepens  into  coma.  Then  he 
develops  an  extreme  dyspnea,  cyanosis  and  Cheyne- Stokes  respiration 
make  their  appearance,  the  temperature  rises,  and  death  comes  on. 

The  test  commonly  employed  for  determining  the  presence  of  an  excess 
of  acetone  is  that  of  Legal:  To  10  cc.  of  urine  in  a  test-tube  add  a  small 
crystal  of  sodium  nitroprussid.  Make  strongly  alkaline  by  the  addition 
of  a  saturated  solution  of  sodium  hydroxid.  Shake.  If  acetone  is  present, 
a  deep  red  color  will  appear,  which  will  change,  on  the  addition  of  a  few 
drops  of  glacial  acetic  acid,  to  a  purple,  which  will  color  the  foam  if  the 
test-tube  be  shaken. 

A  convenient  bedside  test  for  diacetic  acid  is  the  following:  Add  a  few 
drops  of  a  10  or  15  per  cent,  solution  of  ferric  chlorid  to  a  half  test-tube  of 
urine.  A  Burgundy-red  color  shows  the  presence  of  diacetic  acid.  The 
depth  of  color  is  to  a  certain  extent  a  guide  as  to  the  intensity  of  the 
acidosis.  This  is  best  judged  by  putting  one  or  two  fingers  behind  the 
test-tube  to  test  the  transmission  of  light.  If  the  fingers  cannot  be  seen 
12 


178      ACETONEMIA — FATTY  DEGENERATION  OF  THE  LIVER 

through  the  urine,  the  acidosis  is  severe.     If  diacetic  acid  is  present,  acetone 
is  sure  to  be. 

The  treatment  of  acetonemia  consists,  besides  stimulation  as  indicated, 
in  the  employment  of  sodium  bicarbonate  in  large  doses,  by  mouth  or  by 
rectum,  subcutaneously  or  even  intravenously,  in  an  attempt  to  neutral- 
ize the  acids  in  the  blood.  There  can  be  no  question  but  that  the 
exhibition  of  alkalis  in  sufficient  quantity  is  followed  by  immediate  and 
gratifying  relief  of  all  the  symptoms  in  mild  cases.  Sodium  bicarbonate 
should  be  started  as  soon  as  the  diagnosis  is  made,  and  should  be  con- 
tinued until  it  is  clear  that  it  is  no  longer  needed.  By  mouth  it  may  be 
given  in  the  dose  of  20  gr.  every  hour.  In  case  the  vomiting  interferes 
with  its  absorption  by  mouth,  it  should  be  given  continuously  by  rectum, 
in  a  saturated  solution,  by  the  drop  method,  through  a  tube  carried 
high  as  possible.  The  solution  is  readily  absorbed  by  rectum,  and  this 
route  is  usually  the  most  pleasant  and  efficient  of  all.  In  case  of  emer- 
gency a  solution  (6  dr.  to  the  pint)  may  be  given  under  the  breast 
or  into  the  axilla;  there  is  considerable  likelihood  of  abscess  formation, 
however,  as  a  result.^ 

Some  cases  are  apparently  incurable  from  the  start,  and  upon  these 
alkaline  treatment  makes  little  or  no  apparent  impression.  After  coma 
has  set  in,  its  probable  value  is  slight.  There  is  no  argument,  however, 
for  the  abandonment  of  the  use  of  sodium  bicarbonate  early  in  the  attack. 
Guthrie  {op.  cit.)  and  others  hold  that  it  is  extremely  doubtful  if  fatty 
acid  intoxication  is  ever  the  sole  cause  of  death.  Wilbur  ^  has  shown 
experimentally  that  the  acetone  bodies  in  the  blood,  even  after  being 
neutralized  by  sodium  bicarbonate,  are  toxic,  although  in  a  less  degree. 
Bainbridge  {op.  cit.),  laying  stress  upon  the  importance  of  carbohydrate 
deprivation  in  etiology,  declares  that  a  plentiful  supply  of  carbohydrates, 
not  only  in  a  postanesthetic  intoxication,  but  also  as  a  routine  pre- 
ventive measure  before  operation,  appears  to  be  rational  treatment.^  I 
have  personally  observed,  in  confirmation  of  this  statement,  that  dia- 
betics recover  after  operations  with  fewer  complications  and  more  rapid 
healing  of  wounds  if  they  are  put  upon  a  moderate  carbohydrate  diet 
after  operation. 

^  J.  B.  Nichols  (Acid  Intoxication,  Washington  Med.  Ann.,  1908,  vii,  133)  recommends 
the  free  administration  of  alkalis.  Sodium  bicarbonate,  225  gr.  a  day,  plus  calcium  car- 
bonate, 45  gr.,  and  sodium  citrate,  75  gr..  by  rectum,  subcutaneously,  or  intravenously. 
But  even  this,  he  says,  will  produce  no  effect  in  some  cases. 

^  Acidosis,  Jour.  Amer.  Med.  Assoc,  Oct.  22,  1904,  1228. 

^  See  also  W.  Hunter  (Delayed  Chloroform  Poisoning,  Its  Nature  and  Prevention, 
Lancet,  1908,  i,  993)  and  A.  Sippel  (Ein  typisches  Krankheitsbild  von  protrahirten 
Chloroformtod,  Archiv  f.  Gynak.,  1909,  Ixxxviii,  167). 


CHAPTER  XX 

HICCOUGH:  CAUSES;  TREATMENT 

Hiccough,  which  we  ordinarily  consider  simply  as  a  common  and 
trivial  personal  discomfort,  may  in  diseased  conditions  assume  a  posi- 
tion of  considerable  importance.  In  early  times  it  was  considered  as 
a  disease  in  itself,  and  was  so  classified  by  Linnaeus.  Nowadays  it 
is  regarded  only  as  a  symptom,  although  cases  of  apparently  autogenetic 
singultus  have  arisen,  persisted  for  days,  weeks,  or  even  months,  and 
have  gone  on  to  a  fatal  termination,  without  anything  having  been 
observed  during  the  course  of  the  disease  or  at  autopsy  to  account 
direcdy  for  the  phenomenon.  John  Hunter  first  recorded  its  occurrence 
after  operation,  and  it  may  arise  as  a  complication  in  any  disease  at- 
tended with  prostration. 

Pathology. — Hiccough  is  a  reflex  spasmodic  contraction  of  the 
diaphragm,  excited  usually  through  irritation  of  the  terminal  filaments 
of  the  pneumogastric  nerve,  in  the  pharynx,  larynx,  thorax,  esophagus, 
stomach,  or  intestinal  tract.  It  would  seem,  however,  less  frequently 
to  be  due  also  to  direct  irritation  of  the  phrenic  nerve  or  of  the  dia- 
phragm itself,  from  conditions  in  the  lung  or  pleural  cavity,  or  inflam- 
mations or  growths  contiguous  to  the  diaphragm.  Normally,  the 
descent  of  the  diaphragm  is  synchronous  with  the  opening  of  the  glottis; 
the  abnormally  sudden  contraction  in  hiccough  often  catches  the 
glottis  closed  or  half  open,  and  the  incoming  column  of  air  rushing 
through  the  narrow  orifice  causes  the  characteristic  ''hie"  which  gives 
the  popular  name  to  the  "condition.  It  usually  interferes  with  sleep, 
which  adds  to  its  seriousness;  in  sleep  it  may  disappear  altogether,  to 
reappear,  however,  with  awakening;  in  well-developed  cases  it  fre- 
quently persists  in  spite  of  sleep,  though  with  less  frequent  rhythm. 
When  it  once  starts,  it  is  apt  to  continue  indefinitely  from  habit,  even 
after  a  trivial  and  momentary  exciting  cause  has  disappeared,  and  this 
is  especially  apt  to  be  true  in  persons  exhausted  from  illness  or  after 
operation. 

The  commonest  cause  is  the  ingestion  of  gastric  irritants,  such  as 
alcohol,  condiments,  iced  drinks.  It  may  be  the  expression  of  an 
irritation  lower  down  in  the  alimentary  canal,  as  from  worms,  enteritis. 

179 


i8o  hiccough:  causes;  treatment 

In  the  neurotic  it  may  occur  from  mental  emotion,  fright,  or,  arising 
from  some  irritative  cause,  be  continued  as  a  habit.  It  may  occur  in 
the  course  of  a  chronic  nervous  disease,  as  epilepsy,  hysteria,  myelitis. 
It  is  not  uncommon  in  organic  diseases — gout,  Bright's  disease,  con- 
gestion of  the  liver,  pleural  effusion  or  adhesions,  chronic  bronchitis, 
or  unresolved  pneumonia,  phthisis. 

The  most  important  surgical  causes  are  pharyngeal  abscess;  sub- 
diaphragmatic abscess,  empyema,  or  other  intrathoracic  conditions; 
visceral  inflammation,  peritonitis,  gastritis,  incarcerated  or  strangulated 
hernia,  meteorism  or  tympanites;  and  renal  insufficiency  after  opera- 
tions on  the  kidney  or  genito-urinary  tract,  especially  in  elderly  men. 

Prognosis. — An  attack  of  singultus  coming  on  in  a  person  past 
middle  age,  exhausted  by  a  recent  abdominal  or  genito-urinary  opera- 
tion, as  on  the  bowel,  kidney,  or  prostate,  is  generally  considered  of  un- 
favorable import.  In  any  patient  convalescing  from  a  serious  opera- 
tion, if  unchecked,  it  may  become  a  factor  of  grave  importance. 

Treatment. — Since  the  days  when  Pliny  suggested  the  sudden 
exhibition  of  repulsive  reptilians,  to  the  present,  the  treatment  of  hic- 
cough has  been  much  discussed,  and  the  list  of  sovereign  remedies  is 
scarcely  shorter  than  the  list  of  men  who  have  written  on  the  subject, 
but  even  now  cases  are  reported  of  patients  dying  unrelieved,  just  as 
cases  appear  in  which  the  hiccough  stops  as  suddenly  as  it  started,  with- 
out reference  to  treatment. 

It  is  reasonable  to  consider  the  treatment  of  hiccough  under  three 
headings — physiologic,  empiric,  and  antispasmodic. 

It  is  important,  if  possible,  to  find  the  cause  and  relieve  it.  If  no 
direct  cause  can  be  found  to  exist,  treatment  should  be  directed  toward 
any  contributory  cause — renal  insufficiency,  gout,  distention,  con- 
stipation. 

If  direct  or  indirect  cause  cannot  be  found,  or,  if  found,  is  not  amena- 
ble to  treatment,  it  will  become  necessary  to  resort  to  empiric  measures. 
Of  these,  it  is  wise  to  have  a  considerable  number  at  one's  disposal,  for 
often  many  have  to  be  tried  before  one  succeeds.  In  mild  cases  holding 
the  breath,  the  administration  of  hot  water  or  ice,  tongue  traction,  or  tight 
pressure  on  the  costal  margins,  enough  actually  to  relax  the  diaphragm, 
should  first  be  tried.  This  last  procedure  is  called  "throttling  the 
belly" — tight  pressure,  corset  fashion,  with  both  hands  for  three  minutes. 
Local  counterirritation  may  be  applied  by  means  of  ice,  or  ether  or 
ethyl  chlorid  spray  over  the  epigastrium,  the  application  of  a  mustard 
plaster  to  the  epigastrium,  turpentine  stupes  to  abdomen,  ice-bag  to 
spine,  or  electricity  to  diaphragm.     A  tight  adhesive  swathe  may  be 


hiccough:  treatment  i8i 

applied  to  inclose  the  lower  chest.  Depletion  may  be  tried,  if  indicated, 
by  means  of  bleeding,  leeches  to  the  anus  or  epigastrium,  or  by  hot 
mustard  foot-baths.  In  neurotic  cases,  mental  shock  or  the  revulsive 
effect  of  a  cold  shower-bath  may  be  efficacious.  Success  has  been  re- 
ported following  continued  painful  pressure  of  fifteen  or  twenty  minutes 
on  the  supra-orbital  nerve  and  after  continued  pressure  on  the  phrenic 
nerve  in  the  neck.  The  sipping  of  water,  whisky,  or  vinegar  for  the 
purpose  of  bringing  on  a  series  of  frequent  acts  of  swallowing  is  said 
in  many  cases  to  be  of  good  service,  on  the  theory  that  when  the  vagus 
nerve  is  busy  with  the  mechanism  of  swallowing  it  will  weaken  the 
effect  of  the  reflex  to  the  diaphragm.  Swallowing  rapidly  a  considerable 
quantity  of  mush,  gruel,  or  sago,  swallowing  lumps  of  ice,  the  rapid 
eating  of  ice-cream,  have  all  been  stated  to  have  an  effect  in  diminishing 
the  frequency  of  the  spasm  or  in  stopping  it  altogether.  Spraying 
the  pharynx  and  larynx  with  an  anesthetic  solution,  such  as  cocain 
and  menthol  in  chloroform  water,  and  gargling  have  been  of  use,  and 
a  severe  case  has  been  reported  cured  by  the  use  of  apomorphin  to 
induce  vomiting.     Stimulation  is  sometimes  of  avail  in  the  weak. 

Finally,  if  the  case  is  not  one  in  which  a  direct  cause  of  the  phenom- 
enon can  be  arrived  at  or  relieved,  and  if  the  repeated  application 
of  the  empiric  measures  have  resulted  in  no  benefit  to  the  patient,  it 
will  become  necessary  to  resort  to  antispasmodics  and  sedatives.  Of 
these,  the  following  have  been  recommended:  aromatic  spirits  of 
ammonia,  compound  spirits  of  ether  (Hoffmann's  anodyne),  chloral, 
amyl  nitrite,  cocain,  atropin,  morphin,  and,  as  a  last  resort,  to  produce 
sleep  in  cases  which  have  become  exhausted,  inhalations  of  ether  or 
chloroform. 

References 

C.  O'Leary,  Hiccough,  Trans.  Rhode  Island  Med.  Soc,  1894,  v,  91. 

W.  L.  Symes,  On  Hiccough,  Dublin  Jour.  Med.  Sciences,  1892,  xciv,  488;  1895,  xcix,  15. 


CHAPTER  XXI 

THE  TONGUE:  ITS  SIGNIFICANCE 

Observation  of  the  tongue  in  patients  recovering  from  operation 
may  be  of  considerable  value  in  aiding  the  surgeon  to  determine  whether 
the  patient  is  progressing  favorably  or  otherwise.  In  the  old  days 
much  reliance  was  placed  upon  this  observation,  and  many  fine  points 
of  distinction  were  drawn  in  the  endeavor  to  work  out  the  significance 
of  the  changes  which  were  apparent.  Nowadays  we  have  got  into 
the  habit  of  relying  chiefly  upon  the  points  of  pulse,  temperature,  and 
respiration.  The  tongue,  however,  can  assist  us  in  some  doubtful 
conditions.  In  examining  the  tongue  attention  should  at  the  same 
time  be  paid  to  the  following  points:  the  age  of  the  patient,  time  of 
observation,  and  temperature.  Of  the  tongue  itself  the  following 
characteristics  are  to  be  observed:  first,  the  color;  second,  the  fur 
(coat) ;   third,  the  degree  of  moisture;   and  fourth,  the  movements. 

Of  first  importance  are  the  coat  and  degree  of  moisture.  The  coat 
may  be  slight,  in  which  case  the  tongue  presents  a  moist,  thin,  gray 
coat  with  a  pink  background  and  the  sides  and  tip  are  clean.  This 
coat  is  due  to  an  alteration  in  the  amount  and  depositions  of  the  epi- 
thelium covering  and  to  the  accumulation  of  epithelium  and  bacteria. 
If  the  coat  is  thicker,  the  tongue  is  gray  and  in  places  yellow,  or  even 
white  where  the  coat  is  thickest;  if  the  patient  has  been  taking  black 
coffee,  the  coat  may  be  stained  browm;  if  there  has  been  vomiting  of 
bile,  the  coat  may  assume  a  yellow  or  even  an  olive-green  color.  The 
excess  of  epithelium,  due  either  to  overproduction  or  retention,  may 
proceed  to  such  a  point  as  to  give  the  tongue  the  appearance  of  being 
roughly  plastered  over.  In  this  condition  the  breath  is  foul,  and  there 
may  be  ulcers  or  tooth-marks  along  the  margin.  Sometimes  the  filli- 
form  papillae  increase  much  in  size  and  become  lengthened  so  that  they 
stand  out  conspicuously.  This  gives  us  the  appearance  which  is  called 
the  furred  tongue.  This  condition  is  undoubtedly  due  to  disuse  and  to 
want  of  moisture. 

The  coated  tongue  is  usually  moist.  In  contrast  with  this  we  may 
have  a  tongue  which  is  clean  and  without  coat,  dry,  and  glazed.  This 
type  of  tongue  is  to  be  regarded  with  apprehension.     In  contrast  to 

182 


COATED    TONGUE  183 

the  coated  tongue,  which  is  broad  and  flat  with  a  rounded  tip,  this 
tongue  is  narrow  with  a  pointed  tip.  For  the  most  part  the  surface 
is  smooth  and  devoid  of  papillae.  The  tongue  is  liable  to  crack  across 
its  surface.  These  cracks  may  intersect  so  as  to  give  the  appearance  of 
crocodile  hide;  in  color  it  may  be  pale  red  or  yellowish.  It  is  dry  and 
smooth,  as  if  covered  by  a  thin  coat  of  varnish.  The  mouth  above 
shows  an  entire  absence  of  salivary  secretion,  and  the  patient  is  unable 
to  expectorate. 

A  tongue  dried  by  evaporation  soon  becomes  moist  if  rolled  about 
in  the  mouth,  and  its  appearance  is  like  the  moist,  coated  tongue  already 
described.  Dryness  of  the  tongue  is  an  unfavorable  sign  when  the 
patient  cannot,  by  an  effort,  raise  sufficient  saliva  to  moisten  its  surface. 

Clinical  experience  has  shown  that  certain  conditions  in  the  tongue 
are  associated  with  certain  general  conditions  which  make  the  appear- 
ance somewhat  diagnostic.  This  term  must  be  qualified  because  the 
changes  are  so  often  local  or  are  modified  by  conditions  independent 
of  the  general  system.  W.  H.  Dickinson^  describes  twelve  classes  and 
three  subclasses  in  his  lectures  on  the  appearance  of  the  tongue  in 
disease.     The  most  important  of  these  are: 

First,  the  stippled  or  dotted  tongue.  The  tongue  is  moist  and 
dotted  with  little  white  points  representing  an  excess  of  white  epithelium 
on  the  papillae.  It  is  usually  seen  in  persons  in  poor  health,  usually 
from  some  chronic  disease  which  is  not  grave,  and  which  is  not  accom- 
panied by  a  rise  in  temperature. 

Second,  the  coated  tongue.  The  papilla  are  covered  with  white 
epithelium,  and  the  intervals  between  the  papilla  are  almost  filled  with 
epithelium  and  accidental  matters,  so  as  to  form  a  continuous  coat. 
This  tongue,  whether  moist  or  dry,  is  seen  in  acute  and  febrile  diseases 
with  considerable  degree  of  prostration  and  fever. 

Third,  the  plaster  tongue.  The  tongue  is  covered  with  a  thick, 
uniform  coat.  The  papilla  are  elongated.  The  intervals  are  crowded 
with  accumulations.  Saliva  is  deficient.  Fever  and  prostration  are 
marked. 

Fourth,  the  furred  or  shaggy  tongue.  Papillae  are  greatly  elongated. 
This  tongue  represents  an  advanced  stage  in  the  course  of  a  disease.  It 
is  the  result  of  disease  and  want  of  moisture.  The  saliva  is  deficient. 
It  indicates  that  there  has  been  fever  and  that  probably  but  little  food 
has  been  taken. 

Fifth,  the  dry  brown  tongue.  The  surface  is  covered  with  a  dry, 
thick,  felted  coat,  which  is  continuous  and  is  largely  parasitic  in  nature. 

1  Lancet,  1888,  i,  558,  609,  657. 


1 84  THE  tongue:  its  significance 

It  occurs  in  fevers  with  high  temperature  associated  with  prostration 
and  absence  of  sahva.  As  the  patient  gets  better  the  incrustation  dis- 
appears, leaving  a  bare,  red,  dry  surface. 

Sixth,  the  red,  dry  tongue.  This  indicates  a  more  serious  condition 
usually  than  the  dry,  brown  tongue.  It  is  the  tongue  of  chronic  wasting 
diseases,  with  or  without  fever  The  tongue  is  shrunken,  red,  polished, 
and  smooth.  The  papillse  have  disappeared  and  the  epithelium  is 
stripped  off  in  patches. 

Changes  in  the  condition  of  the  tongue  are  frequently  of  local  origin. 
Moisture  of  the  tongue  is  due  to  saliva,  and  any  deficiency  in  saliva  will 
cause  dryness  of  the  tongue.  Saliva  is  deficient  when  fever  is  present, 
and  hence  the  tongue  is  dry.  Dryness  of  the  tongue  may  be  due  to 
increase  of  evaporation,  from  keeping  the  mouth  open,  as  well  as  to 
diminution  of  the  salivary  secretion.  In  chronic  fever  the  effect  of 
the  temperature  upon  the  secretions  in  general  is  to  cause  a  diminution, 
and  this  includes  the  salivary  secretion.  Also  the  general  dehydration 
of  the  body  causes  dryness  of  the  tongue,  even  without  apparent  local 
diminution  of  secretion.  A  tongue  which  otherwise  might  be  dry  is 
sometimes  moist  by  vomit.  Prostration  has  the  same  effect  as  chronic 
fever  in  causing  diminution  of  the  secretion. 

The  ingestion  of  food  influences  the  coating  and  the  degree  of  mois- 
ture. The  act  of  eating  cleanses  the  tongue.  In  such  conditions, 
accordingly,  as  are  accompanied  by  the  decreased  ingestion  of  food, 
it  is  natural  for  the  fur  upon  the  surface  to  become  more  prominent. 
This  is  also  true  in  conditions  where  the  diet  is  limited  to  fluids,  par- 
ticularly milk. 

The  movements  of  the  tongue  when  it  is  projected  have  some  signif- 
icance. The  tongue  may  be  tremulous  in  any  conditions  accompanied 
by  prostration,  etc. 

Dickinson  has  not  been  able  to  discern  any  relationship  between  any 
state  of  the  tongue  and  particular  gastro-intestinal  conditions  apart 
from  that  which  might  occur  from  loss  of  appetite  or  restriction  in  the 
amount  of  food.  The  state  of  the  tongue  is  dependent  not  upon  the 
intestinal  lesion,  but  upon  the  constitutional  disturbance.  The  tongue 
does  not  point  to  particular  organs  or  isolated  disorders,  but  is  the 
gauge  of  the  effects  of  disease  upon  the  system. 

The  condition  of  the  tongue  is,  accordingly,  due  to — (i)  dehydration, 
(2)  exhaustion,  (3)  pyrexia,  (4)  local  conditions  about  the  mouth.  The 
degree  of  fever,  the  state  of  the  nervous  system,  the  maintenance 
and  abeyance  of  secretion,  and  the  failure  of  vitality  are  roughly  in- 


COATED    tongue:   TREATMENT  1 85 

dicated  by  the  condition  of  the  tongue.  The  return  of  the  moisture,  the 
removal  of  fur,  and  subsidence  of  tremor  at  once  indicate  that  the  patient 
is  getting  better.  The  persistence  and  increase  of  these  signs  show  that 
the  disease  is  getting  the  better  of  the  patient.  The  dry  and  bare  tongue 
is  of  serious  prognostic  omen  in  all  conditions. 

So  far  as  is  consistent  with  the  surgical  conditions  present,  any  at- 
tributable cause,  local  or  general,  may  be  treated.  Intestinal  putrefac- 
tion should  be  prevented  by  the  reduction  or  removal  of  proteid,  espe- 
cially meat,  from  the  diet,  by  the  use  of  carbohydrate  food,  such  as  bread, 
cornstarch,  cereals,  etc.,  and  by  the  use  of  laxatives,  buttermilk,  and, 
if  necessary,  internal  antiseptics,  such  as  salol  or  the  salicylates.  Locally, 
■  the  tongue  should  be  cleaned  daily  with  a  tooth-brush,  and  the  use  of  an 
alkaline  liquid,  such  as  liquor  antisepticus  alkalinus,  will  facilitate  the 
removal  of  the  coating.  The  teeth  should  be  looked  after,  if  possible, 
before  every  abdominal  operation. 


CHAPTER  XXII 


BANDAGING 


Bandaging  as  done  to-day  is  an  art  much  simpler  than  as  practised 
a  few  decades  ago.  This  is  in  accordance  with  the  general  trend  of 
surgical  technique,  due  to  our  more  exact  knowledge  not  only  of  the 
pathologic  conditions  present,  but  also  of  the  means  of  correcting  them. 

The  almost  universal  adoption  of  the  gauze  bandage  has  greatly 
helped  this  simplification,  as,  on  account  of  its  texture,  it  can  be  made 
to  adapt  itself  easily  to  the  uneven  surface  presented.  Plaster-of-Paris 
bandage  is  used  for  more  or  less  permanent  fixation,  especially  of  joints 
and  limbs.  Flannel  bandages  and  bandages  made  of  specially  woven 
material,  such  as  the  "Ideal"  bandage,  may  be  used  on  account  of  their 
elasticity  for  the  support  of  strained  joints  and  for  varicose  veins. 

The  other  chief  factor  in  simplification  is  the  almost  exclusive  use 
of  the  "figure-of-8"  instead  of  the  "reverse"  for  the  purpose  of 
closely  and  evenly  fitting  a  part,  the  diameter  of  which  is  increasing. 
In  fact,  this  figure-of-8  principle,  when  thoroughly  mastered,  can  be 
varied  to  fit  any  condition,  and  is  the  basis  of  most  of  the  "named" 
bandages.  It  can  be  applied  much  quicker  than  a  "reverse,"  it  will 
hold  a  dressing  better,  and,  when  finished,  it  is  much  less  likely  to  be- 
come disarranged;  if,  during  its  construction,  several  simple  circular 
turns  are  introduced  on  the  upper  loop  of  the  "8,"  all  tendency  to 
slip  is  overcome,  and  it  is  found  in  good  condition  after  a  week's  con- 
stant wear.  Furthermore,  on  its  removal  the  skin  will  reveal  fewer 
and  less  marked  ridges  than  after  a  "reverse"  bandage;  the  figure-of-8, 
therefore,  is  less  likely  to  cause  localized  pressure — sores  or  venous  stasis 
— ^and  is  of  greater  value  in  such  conditions  as  varicose  veins,  in  which 
an  even  firm  pressure  is  desired. 

Commercial  Roller  Bandages. — Bandages  may  now  be 
bought  made  of  gauze,  flannel,  or  other  material  at  drug-stores  and 
surgical  supply  houses.  These  come  in  any  width,  are  evenly  and 
tightly  rolled,  and  are  usually  economical.  The  ordinarily  employed 
gauze  bandages  come  in  lo-yard  lengths,  and  in  widths  from  i  to  6  in. 
The  commonly  used  sizes  for  practical  purposes  are  the  i^  in.  about  the 
hand  and  head,  and  the  3  in.  about  the  limbs  and  body.     In  an  emer- 

186 


TO   REMOVE   A   BANDAGE  1 87 

gency,  of  course,  any  material  available  can  he  torn  into  strips  and  rolled 
into  a  bandage. 

Cleaning". — The  parts  to  be  covered  in  by  the  bandage  should  be 
cleaned  with  soap  and  water,  followed  by  alcohol,  then  thoroughly  dried 
and  covered  with  dusting-powder. 

Sheet-wadding-  for  Protection. — Before  application  of  a 
bandage  a  layer  of  sheet-wadding  should  always  be  placed  over  the 
dressing  and  the  part  to  be  covered  by  the  bandage.  This  material 
comes  in  sheets  about  a  yard  square,  is  very  soft  and  agreeable  to  the 
skin,  and  nonabsorbent.  It  is  most  easily  applied  by  roughly  tearing 
into  strips,  3  or  4  in.  wide,  and  making  into  rollers,  which  are  then 
applied  loosely  in  spiral  turns;  frequently  two  or  three  strips  are  stitched 
together  so  as  to  form  longer  rollers. 

It  should  be  an  invariable  rule  that,  in  the  application  of  bandages 
or  any  other  apparatus,  no  two  skin  surfaces  should  come  together;   this . 
should  always  be  avoided  by  the  interposition  of  a  piece  of  sheet-wadding 
or  absorbent  cotton,  well  powdered  (for  example,  in  recurrent  bandage 
of  the  hand  the  fingers  should  be  separated  by  sheet-wadding) , 

To  Roll  a  Bandage. — It  is  frequently  necessary  to  reroll  a 
bandage.  To  do  so  fold  one  end  on  itself  several  times  into  a  tight  little 
roll;  grasp  this  at  the  extremities  by  the  thumb  and  forefinger  of  the 
left  hand,  which  act  as  the  bearings  of  the  revolving  axis;  the  free- 
hanging  bandage  is  then  played  between  the  thumb  and  index-finger 
of  the  right  hand,  which,  by  the  alternating  pronation  and  supination 
of  the  forearm,  revolves  the  cylinder  and  the  roller  is  formed. 

To  Start  a  Bandage. — Hold  the  bandage  in  the  right  hand  with 
not  more  than  3  in.  free;  take  the  free  end  with  the  thumb  and  finger  of 
the  left  hand,  lay  the  unrolled  portion  against  the  part  to  be  bandaged; 
hold  the  free  end  firm  with  left  hand;  allow  roller  to  run  to  the  right 
naturally  round  the  part;  as  it  passes  to  the  left  on  the  posterior  surface 
transfer  roller  to  left  hand,  holding  initial  extremity  firm  with  thumb 
of  right  hand;  in  front  change  roller  again  to  right  hand  and  proceed 
as  before,  making  two  complete  turns.  This  turn  is  called  a  circular  turn, 
and  is  used  for  starting  and  "fixing."  This  fixing  should  always  be  at  a 
point  where  there  is  little  or  no  variation  in  diameter,  so  that  it  shall 
not  slip  upward  or  downward  {i.-  e.,  at  the  ankle  and  not  on  the  cone- 
shaped  calf). 

To  Remove  a  Bandage. — Unpin  the  end  and  unwind.  As  the 
bandage  is  being  unwound  the  free  portion  should  be  gathered  into  the 
palm  of  the  hand  and  transferred  bodily  to  the  other  hand  alternately 
above  or  below  the  limb;  it  should  not  be  allowed  to  drag  or  string  out. 


i88 


BANDAGING 


Fig:ure-of-8  Bandage. — After  fixing,  say,  on  the  calf  of  the 
leg,  allow  the  bandage  to  run  diagonally  upward  and  backward  until 
it  reaches  the  posterior  surface,  when  it  will  again  naturally  become 
horizontal;  as  it  comes  around  on  the  other  side,  direct  its  course  onto 
the  front  of  the  leg  diagonally  downward  and  forward,  so  as  to  cross 


Fig.  45- — Application  of  Bandage. 
Preliminary  turns  have   been   taken   to   hold   sheet-wadding.     Figiire-of-8  has  been  used  to  cover  in 
foot,  and  bandage  is  ascending  on  leg.     (The  ends  of  the  gauze  roll  have  been  dipped   in   ink  so  that 
the  turns  may  be  clearly  seen.) 

the  ascending  turn  in  the  middle  of  the  anterior  surface.  Continuing 
to  descend  it  passes  backward  and  becomes  horizontal  on  the  posterior 
surface;  then  it  rises  again  obliquely,  passes  forward,  crosses  the  down- 
ward turn  in  the  middle  of  the  anterior  surface,  and  continues  upward 
and  backward  as  above.  Each  succeeding  turn  progresses  upward 
for  from  h  in.  to  one-half  the  width  of  the  bandage  (Figs.  45  and  46). 


Fig.  46. — Application  of  Bandage  Completed. 
Foot  and  leg  covered  in  with  figure-of-8  turns,  and  circular   used  to  end  off  with. 

The  crossings  on  the  anterior  surface  after  a  little  practice  naturally 
arrange  themselves  in  perfect  alignment.  While  applying  the  bandage, 
an  occasional  circular  turn  helps  to  fix  the  bandage  firmly  and  over- 
comes all  tendency  to  slip;  such  a  turn  usually  falls  naturally,  and 
both  edges  of  the  bandage  lie  flat  and  with  even  tension. 


THE    SPICA   BANDAGE 


189 


The  Spiral  reverse  bandage  was  once  very  generally- 
used  to  cover  any  part  conical  in  shape;  it  is  now  superseded 
by  the  figure-of-8.  It  is  put  on  as  follows:  after  "fixing"  and 
making  one  complete  upward  spiral  turn,  the  hand  holding  the  roller 
is  carried  about  6  in.  away  from  the  limb,  the  thumb  of  the  other 
hand  is  placed  on  the  bandage  ^  in.  proximal  to  proposed  position  of 
the  reverse;  the  hand  holding  the  roller  is  carried  toward  the  limb 
sufficiently  to  slacken  the  unapplied  portion  of  the  bandage,  then,  by 
turning  the  forearm  from  extreme  supination  to  pronation,  the  bandage 
is  twisted  once  on  itself,  so  as  to  form  an  angle  of  about  90°.  The  re- 
verse is  thus  completed,  and  the  bandage  is  allowed  gently  to  fall  flat 
upon  the  limb;  it  is  then  carried  round  underneath  the  limb  and  the 
desired  tension  applied.  The  reverses  should  be  in  a  line  but  not  over 
prominent  parts  (i.  e.,  anterior  border  of  tibia),  as,  unlike  the  figure-of-8, 
they  cause  creases  in  the  skin  which  may  easily  result  in  pressure  sores. 


Fig.  47. — Spica  Bandage  Applied  to  Thigh. 


Fig.  48. 


-Spica  Bandage  Applied  to 
Shoulder. 


The  Spica  bandage  is  really  a  figure-of-8,  one  loop  of 
which  is-  made  much  larger  than  the  other;  there  are  three  situ- 
ations where  it  is  commonly  used — the  thumb,  shoulder,  and  hip. 
The  hip  spica  (Fig.  47),  one  of  the  frequent  dressings  for  hernia,  is 
made  as  follows:  the  bandage  should  be  of  gauze  several  folds  thick, 
12  yds.  long,  and  have  a  width  of  8  to  12  in.  Patient  is  placed  with 
sacrum  resting  on  a  basin  or  spica  block,  sheet-wadding  is  applied  with 
a  considerable  thickness  in  groin.  The  bandage  is  fixed  with  a  circular 
turn  about  the  pelvis;  as  it  passes  from  back  to  front  it  becomes  oblique, 
runs  over  the  inguinal  region  into  groin,  around  the  leg,  up  diagonally 
across  the  inguinal  region  to  the  opposite  side,  and  then  around  the  pelvis; 


IQO 


BANDAGING 


every  third  turn  should  be  a  circular  turn  around  the  pelvis  and  several 
safety-pins  should  be  introduced  during  the  application. 

The  spica  of  shoulder  (Fig.  48)  is  similarly  applied — a  figure-of-8 
with  the  small  loop  about  the  upper  arm  and  the  large  loop  about  the 
thorax,  and  under  the  opposite  axilla. 

To  Bandage  the  Heel. — Frequently  the  heel  is  left  uncovered 
when  bandaging  the  foot  and  leg;  if  it  is  desired  to  include  it  in  the 
bandage,  it  may  be  done  by  one  of  the  following  two  ways: 


Fig.  so. — Leg  Bandage  Applied. 
Side  view,  showing  testudo  to  heel. 


Fig.    51. — Leg  Bandage  Applied. 
Front  view,  showing  crosses  along 
median  line  and  circular  turn  to  end 
off  with  at  top. 


(i)  After  making  fast  by  circular  turns  around  the  ankle  above  the 
malleoli,  the  bandage  is  carried  obliquely  downward  across  the  foot  to 
near  the  base  of  the  toes,  at  which  part  a  circular  turn  is  made.  The 
bandage  is  then  carried  up  the  foot  by  two  or  three  short  figures-of-8; 
then  carried  over  the  point  of  the  heel  and  around  to  the  dorsum  of  the 
foot;  then  beneath  the  instep,  around  one  side  of  the  heel,  and  up  over 


PLASTER-OF-PARIS    BANDAGES  I9I 

the  instep;  from  here  again  beneath  the  instep  around  the  other  side 
of  the  heel  and  up  in  front  of  the  ankle,  from  which  it  may  be  carried 
up  the  leg.     This  is  called  the  French  heel  (Fig.  49). 

(2)  After  fixing  as  above,  the  bandage  is  carried  obliquely  downward 
across  the  foot  to  near  the  base  of  the  toes,  where  a  circular  turn  is 
made;  the  foot  is  covered  nearly  in  with  short  figure-of-8  turns;  when 
running  across  the  top  of  the  instep  the  bandage  passes  over  outer  mal- 
leolus, over  tip  of  the  heel,  and  up  over  inner  malleolus;  then  crosses  top 
of  instep,  around  behind  tendon  of  Achilles,  crossing  again  on  front 
part  of  instep,  it  then  passes  beneath  the  arch  of  the  foot  to  the  front 
of  the  instep.  These  turns  are  continued  in  the  form  of  figures-of-8, 
with  the  point  of  crossing  stationary,  over  the  instep,  and  the  loops 
alternately  covering  the  region  of  the  tendon  of  Achilles  and  the  arch  of 
the  foot,  till  the  heel  is  covered  in,  after  which  the  bandage  ascends  the 
leg.     This  is  called  the  testudo  (Figs.  50  and  51). 

Pressure  Bandage  for  Varicose  Veins  of  the  l,eg. — J.  S. 
Davis  ^  has  recently  described  an  excellent  bandage  for  the  leg,  especially 
where  varicose  veins  are  present.  Elevate  the  leg,  sponge  the  skin  with 
alcohol,  dress  the  ulcer,  and  sprinkle  the  skin  with  dusting-powder. 
Cover  the  entire  area  to  be  bandaged  with  sheet-wadding;  cover  this  with 
either  2-  or  2^-in.  muslin  bandage,  taking  a  loose  turn  around  the  ankle, 
then,  with  ordinary  snugly  fitting  figure-of-8,  bandaging  foot  and 
ankle  from  root  of  toes.  Follow  the  contour  of  the  leg  upward  to  above 
the  calf,  making  both  edges  of  the  bandage  fit  flat;  then,  after  a  circular 
turn,  come  down  the  leg  with  a  long  sweep.  Repeat  the  above,  but 
with  shorter  sweeps,  always  following  the  contour  of  the  leg  and  keep- 
ing both  edges  of  the  bandage  flat.  This  procedure  can  be  repeated 
until  the  dressing  is  thick  enough  to  give  adequate  support,  terminating 
in  one  or  more  circular  turns. 

Plaster-of- Paris  Bandages. — Plaster  of  Paris,  or  gypsum,  is 
used  to  maintain  complete  or  partial  fixation  over  a  more  or  less  extended 
period.  It  forms  a  very  convenient  splint  material  and  is  adaptable 
to  many  places  and  purposes.  It  is  usually  applied,  in  accordance  with 
the  principles  of  technique  just  described,  in  the  form  of  a  bandage. 
This  is  made  by  thoroughly  filling  the  meshes  (16  threads  to  the  inch) 
of  a  gauze  roller  (3  or  4  in.  wide)  with  ordinary  dry  plaster.  Unwashed 
crinolin  probably  makes  the  most  satisfactory  material.  Plaster 
bandages  may  be  bought  at  the  surgical  supply  houses  put  up  in  sealed 
tins.  Care  should  be  taken  that  the  plaster  does  not  become  air-slaked 
by  exposure  to  darpp  air,  otherwise  the  cast  will  crumble  and  disintegrate 

^  Johns  Hopkins  Hosp.  Bull.,  1908,  xix,  114. 


192 


BANDAGING 


after  it  is  applied.     For  this  reason  bandages  that  have  been  in  stock 
for  some  time  should  be  baked  in  an  oven  before  using. 


Fig.  52. — HoFFA  Table. 
For  application  of  plaster-of-Paris  spica.  bandage  to  hip. 

To  apply,  cover  the  leg  smoothly  and  evenly  with  strips  torn  from 
a  sheet  of  cotton  wadding  (Fig.  53),  protecting  amply  all  bony  promi- 
nences.    Completely  immerse  the  plaster  roller  in  luke-warm  water  for 


Fig.  53. — Plaster-of-Paris  Bandage. 
Sheet-wadding  applied.     Foot  held  at  right   angles,  slightly  inverted,  to  overcome  tendency  to  formation  of 

"  flat-foot." 

about  two  minutes,  or  until  all  the  air-bubbles  are  out  and  the  bandage 
wet  through.  A  pinch  of  salt  dissolved  in  the  water  will  hasten  the  set- 
ting; if  it  is  not  dissolved,  it  will  get  into  the  plaster  and  make  it  crumble. 
If  allowed  to  remain  too  long  in  the  water,  the  rollers  set  and  become 


PLASTER-OF-PARIS    BANDAGES  1 93 

hard.     When  taking  the  roller  out  of  the  water,  both  ends  should  be 


Fig.  54. — Plaster-of-Paris  Bandage. 

In  removing  rollers  from  water  the  excess  is 
squeezed  out  by  pressure  on  the  ends,  the  fingers 
being  closed  to  prevent  the  plaster  from  running 
out-  .-, 

F 


Fig.  55.  —  Plaster-of-Paris  Bandage  Im- 
properly Wrung  Out. 

The  twisting  action  wrinkles  the  bandage  and  re- 
moves too  much  plaster. 


Fig.  56. — Plaster-of-Paris  Bandage. 
Roller  being  applied.     The  foot  is  being  correctly  held  by  an  assistant. 

grasped  and  the  water  gently  squeezed  out  (Fig.  54);  a  tv\^isting  or 
wringing  motion  (Fig.  55)  will  force  the  plaster  to  run  out    through 

13 


194 


BANDAGING 


the  meshes.  Roll  around  the  leg  smoothly,  following  the  natural 
curves  with  spiral  or  figure-of-8  turns;  never  use  the  reverse;  never 
pull   tightly;  always  keep  in  mind  the  danger  of  localized  pressure. 


Fig.  57. — Plaster-of-Paris  Bandage. 
The  first  roller  is  being  finished.      This  layer  will  now  be  rubbed  in,    and  a  second   and    third    roller 

similarly  applied. 


After  the  plaster  has  been  applied  about  twenty  minutes,  it  is  in  suitable 
condition  for  trimming,  splitting,  and  cutting  of  windows.  Use  a  small, 
stout  plaster  knife  (shoemaker's  knife)  and  cut  the  plaster  through  until 


Fig.  s8. — Plaster-of-Paris  Bandage. 
Application  has  been  completed,  plaster  has  been  allowed   to  set,  and  has  been  split  down  each  side 
("  bivalved  ")  to  allow  for  swelling  and  for  inspection.     Shows  the  proper  method  of  applicatioa  of  web- 
bing straps  to  keep  the  halves  together. ' 

the  sheet-wadding  is  reached.  This  can  be  cut  later  with  scissors.  It 
is  best  to  defer  removal  of  the  piece  which  has  been  cut  till  the  next  day 
to  allow  the  plaster  to  harden  (Fig.  58). 


MODIFIED    BARTON 


195 


Recurrent  Bandage — Hand  or  Amputated  IVimb.— The  ban- 
dage is  fixed  by  a  few  circular  turns;  then,  when  the  bandage  roll  is  on 
the  front  of  the  limb,  turn  it  at  right  angles,  putting  the  thumb  of  left 
hand  on  the  point  of  folding  to  hold  it  in  place,  carry  the  bandage 
to  the  end  of  the  extremity,  pass  over  this  in  the  median  line,  and  return 
upward  on  the  under  surface  to  a  point  directly  opposite  the  point  of 
starting;  then  place  the  fingers  of  the  left  hand  on  the  bandage,  double 
it  upon  itself,  and  bring  the  bandage  directly  back  the  way  it  came  over 
the  end  of  the  extremity  to  the  point  of  starting.  Each  turn  should 
overlap  two-thirds  of  the  previous  one,  first  on  left  and  then  on  right 
side  of  median  line,  until  the  extremity  is  covered  in;  then  turn  the 
bandage  at  right  angles  so  as  to  secure  the  folds  still  held  by  thumb  and 
finger  with  circular  turns;  the  bandage  may  then  be  continued  up  the 
limb  by  figure-of-8  turns. 

Recurrent  Bandage  of  Head.— Fix  the  bandage  by  two  circular 
turns  around  the  head,  passing  just  above  the  eyebrows  in  front,  as  close 
to  the  tops  of  the  ears  as  possible  on  the  sides,  and  just  under  the  occipital 
protuberance  behind;  with  the 
roller  in  front  take  a  right 
angle  turn,  so  as  to  pass  over 
top  of  head  to  occiput;  double 
back,  and  run  directly  forward 
just  a  little  to  one  side  of  the 
median  line  to  the  root  of  the 
nose;  again  double  backward 
to  the  occiput,  this  time  keep- 
ing just  a  little  to  the  other  side 
of  the  median  line.  The  patient 
can  be  made  to  hold  the  front 
angle  of  turns  and  the  sur- 
geon the  posterior.  Continue 
till  head  is  covered  in,  then  complete  the  bandage  by  several  circular 
turns  about  the  head  to  fix  the  recurrents  in  place.  Pins  may  be  intro- 
duced where  the  recurrent  turns  were  made  to  make  the  dressing  more 
secure  (Fig.  59). 

Modified  Barton. — ^The  bandage  should  be  started  by  t\vo  cir- 
cular turns  around  the  forehead  and  occiput;  then,  as  the  bandage 
leaves  the  occiput,  it  should  pass  forward  in  the  form  of  a  circular 
beneath  the  ear  around  the  front  of  the  chin  and  back  under  the  op- 
posite ear,  where  it  begins  to  run  obliquely  upward,  just  under  the 
occiput  and  under  and  in  front  of  the  parietal  eminence,  across  the 


Fig. 


59. — Recurrent    Bandage    of    Head,    Some- 
times Called  the  "  Melon." 


196  BAXDAGIXG 

vertex  of  the  skull,  downward  over  the  zygomatic  arch,  under  the  chin, 
then  upward  over  the  opposite  zygomatic  arch  and  over  top  of  the  head, 
crossing  the  first  turn  in  the  median  line  and  well  fonvard.  The  bandage 
is  then  passed  obliquely  backward  and  downward  under  the  occipital 
protuberance  and  then  out  once  more  over  the  chin  (Fig.  60).  These 
figure-of-8  turns  are  to  be  continued  until  roller  is  exhausted.     The 

original  Barton's  bandage  omits  the 
turn  around  the  forehead;  this,  how- 
ever, adds  greatly  to  its  stability. 

The  Desault  Bandage. — De- 
sault,^  about  the  beginning  of  the  nine- 
teenth century,  devised  the  following 
apparatus  for  treatment  of  injuries  to 
the  clavicle.  He  placed  a  wedge- 
shaped  pad  in  the  axilla,  which  was 
held  in  place  by  circular  turns  around 
the  body  and  over  the  opposite  shoulder 
(first  roller) ;  the  arm  was  then  securely 
Fig.  6o.-barton^^^^k«d.ge  beixg  ap-     bandaged  against  this  pad  by  circular 

turns,  tighter  near  the  elbow  than  at 
the  shoulder  (second  roll);  forearm  supported  at  right  angles  in  front  of 
the  chest  by  narrow  sling  at  wrist.  The  third  roller  is  then  applied 
to  keep  the  point  of  the  shoulder  elevated;  starting  in  front,  going  toward 
the  injured  side,  the  first  turn  passes  over  the  distal  end  of  the  cla\icle, 
rims  down  back  of  arm  under  elbow,  across  front  of  chest  to  opposite 
axilla,  obliquely  up  across  the  back  over  shoulder,  down  front  of 
arm,  under  elbow,  diagonally  up  and  across  back  to  axilla,  where  it 
again  goes  fonvard  and  upward  to  shoulder  as  before;  these  turns  are 
continued  until  bandage  is  exhausted. 

Velpeau  Bandage.— Velpeau,^  about  1839,  finding  the  Desault 
apparatus  apt  to  cause  serious  pressure  on  the  brachial  vessels  and 
nerves,  adopted  the  following  method  of  application  for  injured  clavicle : 
The  initial  extremity  of  the  bandage  is  placed  in  the  axilla  of  the  well 
side;  it  runs  diagonally  up  over  the  back  and  shoulder  to  the  injured 
clavicle;  the  hand  of  the  injured  arm  is  placed  on  the  opposite  shoulder; 
the  elbow,  therefore,  is  over  the  tip  of  the  sternum,  thus  throwing  point 
of  shoulder  up,  back,  and  outward.     The  bandage  now  runs  down  from 

^  Ocuvres  Chirurgicales  ou  Expose  de  la  Doctrine  et  de  la  Pratique  de  Desault  par 
Xav.  Bichat,  Troisieme  edition,  Paris,  Megnignon,  1813. 

^  \'elpeau,  Nouveux  Elements  de  Medicine  Ope'ratoire,  Deuxieme  edition,  Paris, 
Bailliere,  1839. 


MODIFIED    VELPEAU 


197 


the  clavicle,  first  on  the  anterior  then  on  the  outer  surface  of  the  arm, 
finally  coming  on  to  its  posterior  surface  under  the  elbow  and  out 
over  the  forearm  and  upward  to  the  axilla,  whence  it  started;  these 
turns  are  repeated  twice  to  fix  the  bandage.  Having  completed  the 
second  turn,  carry  the  roller  transversely  around  the  thorax,  passing 
over  the  flexed  elbow  of  the  affected  side  to  point  of  origin;  from  here 
it  runs  obliquely  across  the  back  to  the  injured  shoulder  as  before; 
these  alternating  turns  are  applied  until  arm  and  forearm  are  bound 
firmly  to  side. 

Neither  the  Desault  nor  the  Velpeau  bandage  as  originally  described 
is  frequently  used  at  the  present  time,  but  instead  the  following  modi- 


FiG.  61. — Modified  Velpeau. 
Showiog  preliminary  application  of  sheet-wadding. 
The  bandage  has  been  fixed  and  started  by  two  circu- 
lars about  elbow  and  thorax;  the  second  turn  has  been 
carried  obliquely  upward  across  the  back,  over  the  tip 
of  the  shoulder,  under  the  elbow,  up  over  the  shoulder 
again,  obliquely  down  across  the  chest. 


Fig.  62. — Modified  Velpeax;. 
In  process  of  application,  from  behind,  show- 
ing sheet-wadding    placed  to   protect    axilla    and 
shoulder-tip. 


fication;    this  is  useful  for  any  injury  about  the  shoulder  or  whenever 
it  is  desired  to  have  the  arm  immobilized  against  the  thorax. 

Modified  Velpeau. — First  the  proper  amount  of  padding  is 
placed  in  the  axilla  to  fill  in  the  hollows,  but  this  is  not  of  such  a 
material  as  to  cause  pressure  on  the  axillary  vessels  and  nerves;  sheet- 
wadding  is  placed  also  between  the  forearm  and  chest  (Fig.  61).  The 
bandage  is  fixed  by  tAvo  circular  turns  around  the  arm  and  thorax;  when 
the  roller  reaches  the  axilla  of  the  well  side,  it  passes  diagonally  upward 
across  the  back,  over  the  shoulder  at  its  outer  point  down  to  the  front 


198 


BANDAGING 


of  the  arm,  under  the  elbow,  up  the  back  of  the  arm,  over  the  tip  of  the 

shoulder,  across  the  chest  to  the 
other  axilla  (Fig.  61).  From  here  it 
runs  backward  around  the  thorax 
and  arm,  just  at  the  tip  of  the 
elbow,  returning  to  the  axilla;  then 
the  first  turn  is  repeated  over  the 
shoulder,  down  the  front  of  the 
arm,  under  the  elbow,  up  the  back 
of  the  arm,  over  the  shoulder, 
across  the  chest  to  starting-point, 
from  which  a  circular  turn  is 
made  (Fig.  62).  These  turns  are 
repeated,  leaving  one-third  of  pre- 
ceding turn  uncovered,  up  the  arm 
and  shoulder  until  all  is  covered  in 

Fig.  63. — Modified  Velpeau,  Completed.       Cp^Q     Ao^ 

I^und  Swathe. 1 — The  swathe  as  described  by  Lund  is  a  most 
efficient  method  of  immobilizing  with  comfort  the  forearm  acutely 
flexed  at  the  elbow.  A  cotton  swathe  ^^^^^i^^^^^.  ^  is---^^^ 
of  the  width  of  the  shoulder,  and  long 
enough  to  make  a  figure-of-8  around 
the  elbow  and  body,  is  passed  under  the 
flexed  elbow,  horizontally,  its  center  being 
at  the  point  of  the  elbow.  The  forward 
end  is  carried  snugly  up  around  the  fore- 
arm and  backward  over  the  shoulder, 
diagonally  downward  across  the  back  and 
under  the  opposite  arm,  where  it  is 
pinned  to  the  other  end,  which  is  brought 
forward  to  the  front  and  carried  in  the 
form  of  a  circular  about  the  thorax.  A 
simple  modification  of  this  which  is  often 
used  is  to  continue  the  part  that  passes 
across  the  front  of  the  chest  and  under 
the  opposite  arm  all  the  way  across  the 
back,  to  be  pinned  to  the  part  surround- 
ing the  flexed  arm,  thus  making  a  com- 
plete circular  turn  around  the  body  and 
fixing  the  arm  to  the  body;  the  part  brought  over  the  shoulder  is  pinned 

^  F.  B.  Lund,  Med.  and  Surg.  Reports  of  the  Boston  City  Hospital,  eighth  series,  1857,  p.  3. 


Fig.  64. — The  Lund  Swathe. 
Starting  the  application. 


BREAST    BANDAGE 


199 


to  this  circular  piece  as  it  crosses  the  back   (Figs.  65  and  66).     This 
swathe  can  also  be  applied  advantageously  after  the  method  of  Sayre. 


Fig.  65. — Modified  Lund  Swathe  Applied. 
Showing  sheet-wadding  under  hand. 


Fig.  66. — Modified  Lund  Swathe  Applied. 
Rear  view,  showing  safety-pins  in  place. 


Breast  Bandag-e. — The  Boston  Lying-in  Hospital  ^  bandage  may 
be  easily  extemporized  by  fastening  together  in  the  shape  of  a  T  t^vo 
strips  of  very  stout  linen  cloth,  such  as  towels.  The  strip,  which  forms 
the  tail  of  the  T,  should  be  about  4  in.  broad,  and  long  enough  to  a 
little  more  than  half  encircle  the  patient's  chest.  The  cross-piece 
should  be  nearly  double  that  length,  and  wide  enough  to  extend  from 
a  position  one  inch  below  the  patient's  breast  to  the  edge  of  the  areola. 
This  bandage  is  applied  by  drawing  the  tail  of  the  T  beneath  the  patient's 
back,  in  such  a  position  that  its  ends  appear  at  the  sides,  on  a  line  with 
the  nipples,  and  with  the  junction  of  the  tail  and  cross-bar  well  external 
to  the  edge  of  the  breast  on  that  side.  The  lower  edge  of  the  lower 
half  of  the  cross-bar  should  then  be  drawn  tightly  across  the  chest,  care 
being  taken  to  see  that  it  is  below  the  lower  border  of  the  glandular 
tissue.  It  is  fastened  by  a  safety-pin  to  the  free  end  of  the  tail-piece, 
and  is  prevented  from  slipping  upward  by  attaching  it  to  the  upper 
edge  of  the  obstetric  binder,  at  two  points,  which  should  be  opposite 
the  most  dependent  portions  of  the  breasts.  The  upper  edge  of  the 
other  half  of  the  cross-bar  is  then  drawn  across  the  chest,  entirely  above 
the  breasts,  and  is  pinned  to  the  other  corner  of  the  free  end  of  the  tail- 
piece. It  is  prevented  from  slipping  down  by  shoulder-straps,  not  less 
than  2  in.  wide,  which  are    attached  to  it  opposite  the  upper  edge 


^  Reynolds  and  Newell,  Practice  of  Obstetrics,  1902,  p.  505. 


200  BANDAGING 

of  the  breasts,  carried  over  the  shoulder,  and  pinned  to  the  tail-piece 
in  the  middle  of  the  back.  The  whole  surface  of  the  breasts  should 
then  be  thoroughly  dusted  with  powdered  starch  or  some  other  pow^der 
and  a  large  wad  of  absorbent  cotton  placed  between  them.  The  breasts 
are  then  drawn  strongly  inward  by  the  hands  of  the  patient,  and  the 
bandages  pinned  together  on  each  side  of  the  axilla,  beginning  at  the 
outer  edge  and  then  working  upw^ard  toward  the  nipple,  care  being 
taken  that  the  pressure  is  uniform;  the  edges  of  the  strips  are  then 
brought  together  between  the  breasts  with  safety-pins. 

When  used  to  exert  pressure  upon  badly  caked  breasts,  it  should 
be  drawn  as  tightly  as  possible  without  seriously  embarrassing  respira- 
tion. Its  pressure  there  almost  invariably  results  in  the  expression 
of  all  the  milk,  but  produces  so  much  discomfort  that  it  has  to  be  loosened 
after  a  few  hours. 

To  catch  the  discharge  from  the  breast  a  dressing  can  be  placed 
over  the  nipples  and  held  in  place  by  lightly  pinning  an  extra  piece 
over  the  front  (Figs.  125,  126,  127,  pp.  402,  403). 

Many-tailed  Bandage. — This  consists  of  a  piece  of  cotton  cloth 
of  the  desired  length  and  wide  enough  to  considerably  more  than  sur- 


FiG.  67. — Many-tailed  Bandage  as  Applied  to  Thigh  and  Lower  Abdomen. 

round  the  part;  into  each  side  tears  about  2  in.  apart  are  made.  It 
is  extremely  adaptable  and  very  convenient  for  holding  in  place  wet 
dressings  that  have  to  be  frequently  changed.  The  lower  pair  of  tails 
are  knotted  once  and  the  ends  layed  upward;  the  next  pair  are  knotted 
over  the  ends  of  the  first;  these  ends  are  laid  upward  and  the  third  pair 
knotted  over  them,  etc.,  until  the  last  pair  are  reached;  they  are  tied  in  a 
bow-knot,  so  as  to  be  readily  opened  (Figs.  67  and  68). 

Swathes. — Swathes  are  used  for  maintaining  in  place  abdominal 
and  thoracic  dressings,  and  are  merely  pieces  of  cloth  the  desired  width 
and  length  to  go  around  the  body  and  are  fastened  by  pins  (see  Fig.  137, 

P-  439)- 

T-Bandage. — This  consists  of  a  narrow  belt,  to    the  middle  of 

which  one  or  two  pieces  are  sewed  at  right  angles.     It  is  used  to  hold. 


STRAPPING 


20I 


perineal  dressings  and  vulvar  pads  in  place.  The  cross-bar  of  the  T 
goes  about  the  waist,  the  vertical  limb,  starting  from  the  middle  of  the 
back,  passes  between  the  legs  and  is  carried  up  onto  the  front  of  the 
abdomen.  The  three  ends  meet  and  are  pinned  together  over  the 
pubes. 

Cunningham  Hernia  Dressing.— This  is  made  of  a  piece  of 
Canton  flannel  6  in.  wide  and  i6  in.  long,  to  each  end  of  which  is  sewed 
a  strip  of  adhesive  plaster  about  i6  in.  long.  The  flannel  part  surrounds 
the  leg;  the  adhesive  pieces  cross  over  the  inguinal  region  and  adhere 
to  the  flanks.     (For  illustration,  see  Fig.  138,  p.  440.) 

Strapping  Abdominal  Wound.— A  very  neat  way  is  to  use  t^\  o 
pieces  of  adhesive  plaster  of  the  requisite  size;  on  the  ends  next  to  the 
wound  are  fixed  three  or  four  dressmakers'  hooks.     After  the  dressing 


Fig.  68. — Many-tailed  Bandage  Holding  Fomentations  to  Hand  and  Forearm. 
The  patient  and  bed  are  protected  by  a  rubber  sheet. 

is  in  place  the  desired  tension  can  be  obtained  by  lacing  the  two  ends 
together.     (For  illustration,  see  Fig.  144,  p.  456.) 

Strapping  the  Ankle. — Take  about  six  pieces  of  adhesive 
plaster,  i  in.  wide  and  18  in.  long.  To  relieve  and  fixate  the  internal 
ligament;  start  the  first  piece  on  the  dorsum  of  the  foot,  pass  outward 
around  outer  edge,  beneath  the  arch,  up  the  inner  side  diagonally, 
up  the  ankle  to  the  outer  side  of  the  calf;  apply  all  the  strips  each  over- 
lapping about  one-half  inch.  To  splint  the  external  ligament  reverse 
the  direction  (Fig.  69). 

Strapping  the  Ribs. — Have  six  to  eight  adhesive-plaster  strips, 
2  in.  wide  and  long  enough  to  encircle  the  body;  direct  the  patient  to 
stand  with  arms  elevated  and  the  uninjured  side  next  to  the  surgeon. 
Apply  the  initial  end  of  one  strip  to  the  side  and  order  the  patient  to 
turn  around.     The  patient  then  proceeds  to  wind  himself  up  into  the 


202 


BANDAGING 


plaster;  the  amount  of  tension  will  be  regulated  by  the  resistance  which 
the  surgeon,  holding  the  unattached  end  of  the  plaster,  offers.  Each 
strip  overlaps  one-third  of  the  preceding  strip.  This  is  more  effective 
in  controlling  the  pain  accompanying  respiration  than  strapping  one- 


FiG.  69. — Strapping  the  Ankle. 
The  strip  of  adhesive  plaster  is  started  on  the  outer  border  of  the  foot,  carried  under  the  arch,  and  across 

to  the  outer  aspect  of  the  leg. 

half  of  the  thorax,  as  often  recommended.  When  many  ribs  are  frac- 
tured, care  must  be  taken  not  to  apply  too  tightly,  as  there  is  danger 
of  causing  inward  buckling  of  the  fragments  with  increase  in  pain.  : 

Strapping   the   Knee.— Take  three  pieces  of  adhesive  plaster, 
i^  in.  wide  and  9  in.  long,  apply  one  strip  above  and  one  below  the 


Fig.  7o.^Strapping  Applied  to  Knee. 

One  strap  above  patella   pulling  downward;   one  below   patella  pulling  upward;   one  over  patella.     Each 

goes  only  from  hamstring  to  hamstring. 

patella,  and  the  third  piece  directly  over  the  patella,  running  transversely 
from  one  hamstring  to  the  other,  overlapping  the  other  two  about  i  in. 
(Fig.  70). 


SLINGS 


203 


Sling". — A  piece  of  cloth  to  be  used  as  a  sling  is  usually  cut  in  the 
form  of  a  right-angled  triangle,  with  the  legs  about  20  or  22  in.  long  for 
an  adult.  It  is  used  to  support  a  part,  especially  the  forearm.  The 
right  angle  is  placed  at  the  elbow,  the  forearm  rests  in  the  trough  as  the 
ends  of  the  string  are  brought  up,  one  in  front  of  and  one  behind  the 
forearm,  and  tied  or  pinned  at  the  neck.  A  pinned  sling  is  much 
neater  and  less  irksome  than  the  tied  one  (Fig.  71).  If  it  is  tied,  care 
should  be  taken  that  the  knot  is  to  one  side  or  the  other  of  the  median 
line.  The  sling  should  include  the  entire  hand,  and  a  pin  or  two  may 
be  necessary  at  the  elbow. 

Double  Sling. — Instead  of  using  a  modified  Velpeau  a  so-called 
double  sling  may  be  employed  to  support  the  forearm  and  hold  the 


Fig.  71. — Showing    Method  of  Pinning  Cor- 
ners OF  Sling  so  That  They  Lie  Flat. 


Fig.  72. — Double  Sling  Applied. 
Note  how  the  hand  is  supported. 


humerus  against  the  side.  The  first  sling  should  be  applied  as  already 
directed.  The  right  angle  of  the  second  sling  should  be  placed  at  the 
shoulder  and  the  long  edge  at  the  elbow.  The  two  ends  are  pinned 
together  in  opposite  axilla  (Fig.  72). 

Suspensory  Bandages. — The  object  of  suspensory  bandages  is 
to  keep  the  testicles  elevated.  The  objections  to  the  many  forms  of 
commercially  made  suspensories  are  in  the  main  two: 

First,  that  they  are,  as  a  rule,  made  in  three  sizes,  and,  unless-  the 
physician  instructs  the  patient  as  to  the  size  necessary  in  the  given  case, 
the  bandage  may  be  too  large  to  keep  the  testicles  elevated  or  so  small 
as  to  exert  undesired  pressure  on  the  organs.  Also  if  the  suspensory 
bandage  is  used  for  a  swelling  of  the  testicles,  the  bandage  becomes  too 
large  as  the  swelling  subsides. 


204 


BANDAGING 


The  second  objection  is  that  the  majority  of  suspensory  bandages 
exert  pressure  in  the  region  of  the  external  abdominal  ring,  as  the  belt 


Fig.   73. — Hammock   Suspensory   (Cunningham). 
Webbing  belt  abou    the  waist.     Under  half  of  Can- 
ton flannel  hammock  buttoned  in  place. 


Fig.  74. — Hammock  Suspensory. 
Anterior  half  buttoned  up  in  position. 


holding  the  bandage  usually  presses  over  this  area.     It  is  believed  that 
this  sometimes  hinders  the  drainage  of  inflammatory  products  through 

the  vas  deferens  in  instances  of 
epididymitis.  It  also  exerts  a  del- 
eterious influence  in  varicoceles  of 
large  size,  hindering  the  flow  of 
blood  from  the  veins  of  the  cord, 
and  thus  inducing  and  maintain- 
ing congestion. 

With  the  end  in  view  of  over- 
coming these   objections   the   fol- 
lowing forms  of  suspensory  band- 
age, which  are  adjustable  in  size 
and    exert    no    pressure  over  the 
spermatic  cord,  have  been  devised 
by  Dr.  John  H.  Cunningham,  of 
Boston,  for  the  purposes  indicated. 
Hammock    Suspensory. — This 
suspensory     is     made    of    heavy 
Canton  flannel.     It  consists  of  an  oblong  piece  of  flannel,  16  in.  long 
by  8  in.  wide,  from  the  ends  of  which  a  V-shaped  piece  is  removed.     A 
buttonhole  is  cut  in  each  corner.      A  webbing  belt  is  placed    about 


Fig.  75. — Hammock  Suspensory. 
Hole  cut  in  anterior  half  for  urination. 


SUSPENSORY    BANDAGES 


205 


the  waist  and  buckled.  On  this  webbing  belt  are  sewed  two  buttons, 
occupying  positions  over  the  anterior  superior  spines  of  the  ilia.  The 
suspensory  is  placed  well  under  the  scrotum,  with  the  soft  side  of  the 
Canton  flannel  against  the  scrotum,  and  the  upper  ends  of  the  suspen- 
sory buttoned  in  position  (Fig.  73).  The  lower  ends  are  now  turned 
up  over  the  scrotum  and  penis  and  also  buttoned,  holding  the  scrotum 
in  the  hammock  (Fig.  74).  If  there  is  so  much  pressure  in  the  peri- 
neum as  to  be  uncomfortable,  the  waistband  may  then  be  adjusted. 
No  perineal  straps  are  necessary.  When  urination  becomes  necessary, 
the  two  lower  arms  may  be  unbuttoned  and  the  bandage  dropped,  or 


Fig.    76. — Adhesive    Plaster    Suspensory 
(Cunningham). 
The  initial  end  has  been  made  fast  across  the 
perineum.     The  two  sections  of  the  strap  are  being 
drawn  up  onto  the  abdomen  under  considerable  ten- 
sion. 


Fig.  77. — Adhesive    Plaster  Suspensory  Ap- 
plied. 
Note  the  efficiency  with  which  the  scrotum  is  sup- 
ported against  the  pubes. 


a  hole  may  be  cut  in  the  suspensory  through  which  the  penis  is  drawn 

(Fig-  75)- 

Adhesive  Plaster  Suspensory. — This  method  of  suspension  may  be 
used  with  advantage  in  all  operations  upon  the  scrotum  in  which  the 
scrotal  incision  has  been  completely  closed,  in  ambulatory  cases  of 
epididymitis,  and  in  all  other  cases  of  epididymitis  in  which  applica- 
tions to  the.  skin  are  not  used.  In  operative  cases  it  prevents  the  scro- 
tum from  hanging  down  and  thus  increasing  the  tendency  to  infiltration 
of  blood  into  the  lax  scrotal  tissues.  In  the  ambulatory  cases  of  epi- 
didymitis the  scrotum  is  supported  continuously,  and  the  bandage  can- 


2o6  BANDAGING 

not  be  loosened  up  or  removed  by  the  patient,  as  is  sometimes  to  be 
feared,  especially  in  the  class  of  patients  which  are  accustomed  to  fre- 
quent the  out-patient  clinics. 

The  suspensory  consists  of  a  piece  of  adhesive  plaster,  5  in,  wide 
by  12  in.  long,  and  is  applied  as  follows:  Patient  lies  with  the  legs 
spread  apart.  The  scrotum  is  held  elevated  by  an  assistant.  The 
adhesive  plaster  is  placed  across  the  perineum  on  a  line  with  the  junction 
of  the  scrotum  and  the  perineum.  The  plaster  is  then  brought  upward 
across  the  scrotum,  and  split  in  the  center  from  the  upper  end  down- 
ward to  a  point  corresponding  to  the  junction  of  the  penis  and  scrotum 


Fig.   78. — Perineal  Dressing  (Cunningham). 

(Fig.  76).  The  penis  is  drawn  forward  into  the  apex  of  this  slit  and 
the  two  ends  fastened  to  the  abdomen  (Fig.  77).  The  plaster  is  then 
made  to  fit  the  sides  of  the  scrotum  by  sticking  the  two  free  edges  to- 
gether.    In  the  upright  position  the  testicles  are  held  elevated. 

If  a  large  scrotal  dressing  is  employed,  an  additional  strap  placed 
across  the  scrotal  bandage  and  fastened  to  either  side  of  the  scrotum  may 
be  of  service. 

Perineal  Dressing  Bandage. — This  consists  of  a  waistband,  48  in. 
long  and  5  in.  wide,  in  the  center  of  which  are  sewed  2  flaps,  36  in.  long, 
one  of  which  is  split  in  the  center  (Fig.  78).  It  is  applied  as  follows: 
Patient  is  in  the  dorsal  position,  with  the  legs  spread  apart.     The 


PERINEAL    DRESSINGS 


207 


waistband  is  fastened  about  the  waist  by  safety-pins.  The  scrotum 
is  held  elevated  by  an  assistant  and  the  perineal  dressing  applied.  The 
two  flaps  are  crossed  over  the  dressing  and  a  large  safety-pin,  including 


Fig.  79. — Perineal  Dressing. 
The  narrow  flaps  are  crossed  and  pinned  in  the  perineum;   the  wide  flap  is  lying  upon  the  table. 

the  dressing,  is  placed  in  the  center  of  the  perineum  (Fig,  79).    The 
edges  of  these  flaps  are  united  by  safety-pins  around  the  scrotum,  which 


Fig.  8(5. — Perineal  Dressing. 
Narrow  flaps  pinned  to  belt. 


is  held  in  an  elevated  position.  These  flaps  are  then  united  to  the 
waistband  by  safety-pins  (Fig.  80).  The  perineal  dressing  is  thus 
held  firmly  in  position  and  the  testicles  are  elevated  and  held  securely 


208 


BANDAGING 


away  from  the  perineal  wound.  The  large  flap  is  then  turned  up 
and  fastened  to  the  waistband,  thus  covering  the  under  flaps  and 
scrotum,  aiding  in  support  and  in  appearance  (Fig.  8i).     If  a  cath- 


FiG.   Si. — Perineal  Dressing. 
Application  finished  by  pinning  up  the  wide  flap. 


eter  is  placed  in  the  bladder  through  the  perineal  wound,  the  two  flaps 
are  pinned  around  it  and  the  outer  flap  perforated. 


CHAPTER  XXIII 

TREATMENT  OF  THE  OPERATIVE  WOUND:  DRESSING, 
STITCHES,  DRAINAGE,  AND  STITCH  ABSCESS 

Time  for  Dressing. — The  natural  tendency  of  wounds  is  to 
heal  aseptically  by  first  intention,  and  accordingly  it  is  not  advisable, 
as  a  rule,  to  disturb  the  sterile  dressing  applied  at  the  time  of  operation 
until  the  time  for  the  removal  of  the  stitches  is  due.  Yet  suppuration 
may  take  place  where  it  is  the  least  expected — any  one  of  many  factors, 
such  as  septic  suture  material,  stitches  tied  too  tightly,  blood-clot    in 


Fig.  82. — Layout  for  Abdominal  Dressing. 
Probe,  director,  blunt  scissors,  hemostats,  irrigating-tip,  toothed  and  smootli  forceps. 

the  wound,  etc.,  may  enter  in  to  mar  an  otherwise  perfect  healing.  Ac- 
cordingly, it  is  of  considerable  importance  to  detect  the  presence  of 
suppuration  at  the  earliest  date  possible,  that  it  may  at  once  be  ade- 
quately dealt  with,  and  prevented,  if  may  be,  from  spreading  to  the 
whole  wound;  if  this  is. neglected,  when  the  time  comes  to  remove  the 
stitches  the  wound  will  be  found  separated  and  more  or  less  broken 
down  and  the  dressing  saturated' with  pus. 

The  most  valuable  guide  to  the  septic  or  aseptic  state  of  the  wound  is 
the  temperature  chart  (see  p.  52).  Ordinarily,  after  any  perfectly  aseptic 
operation,  it  is  the  rule  to  find  the  temperature  rising  to  between  99° 
and  100°  F.  within  forty-eight  hours  after  the  operation,  as  has  been 

14  209 


2IO  TREATMENT    OF    THE    OPERATIVE    WOUND 

detailed  before.  This  is  a  favorable  reaction;  in  the  worst  cases  it  does 
not  occur  or  it  may  be  replaced  by  a  depression.  The  temperature 
reaches  normal  again  by  the  afternoon  of  the  third  day.  If  the  tem- 
perature does  not  drop  on  the  third  day,  or  if,  having  reached  nor- 
mal, it  rises  again  at  any  time  from  the  third  to  the  sixth  day,  sepsis 
in  the  wound  is  to  be  strongly  suspected,  and  the  wound  should  be 
examined  under  aseptic  precautions.  Pain  referred  to  the  site  of  a 
wound  appearing  on  the  third  day  or  after,  under  conditions  where 
pain  would  not  be  expected,  is  frequently  a  sign  of  inflammation  and 
sepsis. 

On  examination,  however,  it  may  be  found  that  the  pain  is  due  to 
the  irritation  of  the  stiff  suture  ends  pricking  or  scratching  the  skin,  or 
to  the  discomfort  of  the  gauze  which  is  next  the  wound  becoming  caked 
from  the  dried  blood  or  serum.  In  either  case  relief  may  be  afforded 
by  applying  new  sterile  gauze  next  the  wound,  by  means  of  sterile 
forceps,  removing  the  caked  gauze,  and  reapplying  the  old  dressing. 
Sutures  causing  irritation  may  be  rearranged  or  snipped  off.  In  this 
procedure  it  is  not  necessary  to  touch  the  wound  or  the  gauze  except 
with  sterile  forceps. 

Aseptic  Wounds. — Unless  there  is  some  good  indication, — for 
instance,  the  dressing  has  become  loose  and  misplaced,  has  been  soiled, 
or  soaked  with  blood  or  serum, — the  dressing  should  not  be  disturbed 
until  the  time  set  for  the  removal  of  the  stitches.  The  small  amount 
of  blood  and  serum  which  ordinarily  soaks  into  the  dressing  from  a 
tightly  closed  wound  becomes  coagulated  in  the  air,  at  the  same  time 
serving  to  seal  the  wound  and  to  splint  and  support  the  skin-edges.  If 
the  hemorrhage  or  serous  effusion  has  been  so  considerable  as  to  soak 
the  dressing  through,  so  that  the  outermost  layers  are  moist  and  damp, 
the  dressing  should  be  changed,  because  the  moist  areas  serve  as  an 
admirable  breeding-place  for  bacteria,  along  which  their  growth  may 
rapidly  proliferate  until  they  reach  the  wound.  If  for  any  reason  it 
becomes  necessary  to  change  an  aseptic  dressing,  all  the  proprieties  of 
aseptic  technique  should  be  observed  with  the  utmost  exactness.  It 
is  best  to  leave  in  place  untouched  the  innermost  layers  of  gauze  which 
are  in  direct  apposition  to  the  wound. 

STITCHES 

A  good  rule-of- thumb  as  regards  the  removal  of  sutures  is  "'  stitches 
out  on  the  seventh  day."  This  applies  to  the  vast  majority  of  aseptic 
cases.  If  the  wounds  are  small,  and  if  they  are  on  the  face  or  neck, 
where  healing  is  rapid  and  the  best  cosmetic  results  are  desired,  and 


REMOVAL    OF    STITCHES  211 

if  the  stitches  are  under  no  tension  and  simply  maintain  the  skin-edges 
in  approximation,  they  may  be  removed  as  early  as  the  third  day.  If 
this  is  done,  it  is  well  to  hold  the  skin-edges  together  for  a  few  days 
longer,  either  by  narrow  strips  of  adhesive  plaster  or  by  gauze  or  crepe 
lisse  and  collodion,  so  that  they  may  not  be  pulled  apart  by  muscle 
action  or  by  any  sudden  strain.  If  the  wound  is  long  and  deep,  if 
the  sutures  hold  the  parts  together  under  considerable  tension,  the 
wound  is  so  situated  that  muscle  pull  would  tend  to  separate  the  edges 
or  stretch  the  scar,  or  if  a  great  deal  depends  upon  the  sutures,  as,  for 
instance,  in  the  case  of  a  laparotomy  sewed  up  rapidly  by  mass  sutures 
of  silkworm  gut,  the  stitches  should  not  be  removed  until  ten  days 
or  t^vo  weeks  have  elapsed,  and  then,  if  there  is  any  question  of  the 
ability  of  the  scar  to  stand  the  strain  to  which  it  will  be  subjected,  the 
strain  should  be  relieved  by  adhesive  straps,  a  swathe,  bandage,  or  some 
other  device. 

In  a  long  abdominal  wound,  or  in  any  case  where  a  great  number 
of  skin  sutures  have  been  taken,  as  after  amputation  of  the  breast,  the 
stitches  may  be  removed  by  stages,  at  intervals  of  a  day  or  two,  partly 
for  the  comfort  of  the  patient  and  partly  to  test  the  healing  of  the  inci- 
sion. As  a  general  rule,  the  sutures  holding  the  skin-edges  should  be 
removed  first  and  the  tension  sutures  last,  unless  there  is  reddening  of 
the  skin  about  the  tension  sutures,  w^hen  they  should  be  taken  out  first. 
Some  English  surgeons  leave  their  sutures  in  place  after  a  celiotomy 
for  as  long  as  three  weeks.  This  does  fairly  well  with  silkworm  gut  or 
horsehair,  but  a  silk  suture,  whether  on  account  of  its  irritant  action 
on  the  tissues  or  on  account  of  its  great  capillarity,  is  apt  to  show  signs 
of  infection  after  a  week  or  ten  days,  and  it  should  not  be  left  in  any 
longer  than  that.  If  the  wound  has  been  sutured  with  a  running  stitch 
of  plain  catgut^  a  w^eek  or  ten  days  usually  suffices  to  soften  up  the  catgut 
under  the  skin  sufficiently  so  that  a  gentle  pull  will  bring  away  the 
remains. 

Patients  have  been  taught  to  look  forward  with  some  apprehension 
to  the  removal  of  stitches.  It  is  only  in  rare  cases  that  the  removal 
causes  actual  pain,  and  then  it  is  frequently  due  to  a  dull  pair  of  scis- 
sors or  an  unsteady  hand.  The  relief  that  is  felt  after  the  sutures  arc 
out,  the  knowledge  that  the  dread  ordeal  is  over,  coupled  with  the  as- 
surance from  the  surgeon  that  the  wound  is  healing  nicely,  more  than 
suffice  to  pay  for  whatever  petty  discomfort  may  attend  the  process 
of  removal.  As  with  all  dressings, — and  this  applies  particularly  in 
a  hospital, — preparations  should  be  made  quietly  and  out  of  sight  of 
the  patient.     The  only  instruments  absolutely  necessary  are  scissors 


212  TREATMENT    OE    THE    OPERATIVE    WOUND 

and  forceps.  A  pair  of  slender-bladed  "double-blunt"  scissors  should 
be  selected  which  will  cut  at  the  point.  They  should  be  tried,  before 
boiling,  on  loose  absorbent  cotton;  if  the  tips  do  not  cut  clean,  or  if 
there  is  any  pulling  of  the  fiber,  they  should,  if  we  are  particular  of 
our  patient,  be  rejected.  There  is  a  special  instrument  used  at  the  St. 
Mary's  Hospital,  Rochester,  Minn.,  called  the  Littauer-Paynes  stitch 
scissors  (Fig.  83).  Both  of  the  blades  are  blunt,  making  it  impossible 
to   injure   the   tissue  while   removing   the   stitches.     The   stitches  are 

lifted  aw^ay  from  the  skin  by 
the  hook  at  the  end  of  the  lower 
blade. 

The  forceps  should  be  the 
so-called  "anatomic"  forceps, 
with  rather  weak  spring  and 
slender  points.  These,  w^ith  the 
scissors,  should  be  boiled  in 
sodium  bicarbonate  water  in  the 
tray  from  which  they  are  to  be 

Fig.  83.— Scissors  (Littauer-Paynes)  Designed  for       uScd — not  long  CnOUgh  tO  injure 
Removal  of  Stitches.  .  ,  .    ,  . 

the  cuttmg-edge  of  the  scissors — • 
the  water  poured  off,  and  the  tray  placed  upon  the  table  or  bedside  "car." 
The  car  should  carry,  in  addition,  a  basin  of  corrosive  sublimate  or 
weak  alcohol  for  the  surgeon's  hands  or  to  wipe  the  skin  clean  of  dried 
blood,  an  empty  basin  to  hold  the  soiled  dressing,  sterile  gauze  in  can 
of  package  for  the  new  dressing,  a  sterile  towel,  bandage  scissors,  ab- 
sorbent cotton,  adhesive  plaster,  bandage  or  swathe  as  needed,  and 
a  clean  sheet  or  t^;\'0  to  drape  the  patient.  Before  the  car  is  wheeled  in 
the  one  in  charge  should  assure  himself  that  everything  which  may  be 
necessary  is  at  hand,  for  nothing  suggests  to  the  patient  incompetency 
so  much  as  the  necessity  for  holding  up  in  the  midst  of  a  dressing  while 
a  nurse  is  scurrying  about  for  some  forgotten  collodion,  adhesive,  or  other 
matter. 

The  surgeon  scrubs  his  hands  clean,  using  especial  care  if  he  has 
recently  come  in  contact  with  a  septic  case,  w^hile  the  nurse  wheels  in 
the  car,  arranges  the  screens,  drapes  the  patient,  and  removes  the 
bandage  or  swathe.  Then  the  nurse  removes  or  turns  back  the  outer 
layers  of  the  dressing,  down  to  the  gauze  in  contact  with  the  wound, 
which  she  takes  care  not  to  touch.  The  surgeon  can  now  remove  the 
dressing  without  breaking  his  asepsis.  So  far  as  possible  everything 
should  be  done  with  instruments — scissors,  director,  hemostatic  or 
thumb-forceps  (Fig.  82).     If  the  dressing  has  "caked"    and  stuck  to 


REMOVAL   OF    STITCHES  213 

the  wound  and  sutures,  the  gauze  may  be  moistened  with  the  antiseptic 
solution  to  avoid  pain  in  pulling  it  off. 

In  cutting  the  sutures  the  surgeon  should  grasp  one  end  with  the 
forceps  and  pull  slightly,  on  one  side,  so  as  to  expose  a  bit  of  the  suture 
which  has  been  buried.  The  scissors  should  now  be  slipped  flat  under 
the  suture,  and,  the  points  being  depressed  so  that  they  will  divide  a 
part  of  the  suture  which  has  not  previously  been  exposed,  the  suture 
is  cut  and  removed  by  a  quick  movement  of  the  hand  holding  the  for- 
ceps. If  these  procedures  are  accomplished  rapidly  and  deftly,  with 
a  steady  hand,  there  will  be  no  pain.  The  suture  should  be  lifted  before 
cutting  for  t^vo  reasons — because  the  exposed  portion  of  the  suture  may 
carry  infective  material  which,  being  wiped  off  as  it  is  pulled  through  the 
skin  and  subcutaneous  tissue,  may  give  rise  to  sepsis  in  the  wound, 
and  because  the  suture  material,  especially  if  it  is  stiff,  as  silkworm 
gut,  is  apt  to  bend  at  a  sharp  angle  just  at  the  skin  level,  and  if  this  kink 
is  pulled  through  the  suture  track,  it  will  cause  pain.  The  direction 
of  the  pull  should  always  be  straight  upward  or  toward  the  incision, 
partly  because  the  suture  comes  out  more  readily,  partly  because  if  the 
suture  sticks,  a  pull  away  from  the  wound  is  likely  to  pull  the  edges 
apart.  If  the  suture  does  not  come  away  at  the  first  effort,  the  tips  of 
the  scissors,  separated  slightly,  can  be  used  to  make  counter-pressure 
on  the  skin  on  either  side  of  the  hole  from  which  the  suture  is  being 
pulled.  In  persons  with  fat  abdominal  w^alls,  if  considerable  tension  is 
placed  upon  the  sutures,  they  may  be  actually  buried  out  of  sight.  In 
this  case  one  of  the  long  ends  must  be  grasped  and  pulled  until  the  knot 
is  brought  to  view,  when  it  can  be  divided  below  the  knot. 

If  the  wound  edges  have  been  brought  together  by  intracuticular 
stitch,  the  same  procedure  should  be  adopted.  If  the  wound  is  a  long 
one,  sometimes  it  is  difficult  to  pull  the  stitch  out;  to  avoid  breaking,  it 
is  wise  to  take  a  grip  with  the  forceps — the  other  protruding  end  being 
cut  short  below  the  skin — and  slowly  wrap  the  suture  about  the  forceps, 
by  revolving  the  forceps  between  the  fingers  while  pulling.  If  the 
suture  breaks  under  the  skin,  as  it  sometimes  does,  the  wound  edges 
should  be  gently  separated  with  the  scissors  tip  at  a  point  about  the 
middle  of  the  fragment  left  behind,  the  suture  grasped  and  removed 
through  the  wound.  The  separated  edges  should  be  held  approximated 
by  collodion  or  adhesive. 

Many  fanciful  and  artistic  devices  have  been  suggested  for  holding 
wound  edges  together  by  means  of  adhesive  plaster,  mostly  with  the 
intent  of  providing  a  narrow  bridge  of  adhesive  at  the  point  where  it 
crosses  the  wound,  or  of  doing  away  with  this  bridge  altogether.     These 


214  TREATMENT    OF    THE    OPERATIVE    WOUND 

include  the  butterfly  and  dumb-bell  plasters  and  the  dumb-bell  and 
window  plaster  previously  described,  and  plaster  strips  incorporating 
hooks  and  eyes,  hooks  to  be  laced  over  the  wound  (Fig.  144,  p.  456.) 
or  to  be  approximated  with  rubber  bands,  and  strips  incorporating  silk 
ties,  to  be  tied  over  the  wounds.  These  devices  are  usually  unnecessary. 
Narrow  strips  of  plaster  of  good  length,  if  applied  while  proper  approx- 
imation is  being  made,  suffice  for  this  purpose. 

DRAINAGE 

Drainage  is  provided  for  one  of  three  reasons — hemorrhage,  serous 
oozing,  and  sepsis.  Depending  upon  the  situation,  the  size  of  the 
wound,  and  the  purpose,  a  drain  ordinarily  may  consist  of  one  or  more 
strands  of  catgut,  the  selvedge  of  sterile  or  iodoform  gauze,  a  piece  of 
rubber  dam  doubled  upon  itself  or  coiled  in  the  form  of  a  cornucopia, 
strips  of  gauze,  or  a  glass  or  rubber  tube.  After  operations  involving 
considerable  dissection,  if  muscle  is  divided  and  there  is  oozing  of  blood, 
as  after  a  thigh  amputation,  or  if  there  are  any  pockets  in  which  serous 
ooze  might  collect,  as  in  the  axilla  after  a  breast  amputation,  it  is  well 
to  put  a  drain  in  at  the  most  dependent  point;  rubber  dam  is  best,  be- 
cause it  will  not  plug  up  the  opening  and  can  be  removed  readily  and 
without  pain.  In  case  of  sepsis  we  are  apt  to  use  gauze  or  rubber 
tubing,  and  this  condition  we  will  consider  later. 

In  an  aseptic  wound  it  is  not  desirable  to  leave  drainage  any  longer 
than  is  necessary  to  subserve  the  purpose  for  which  it  is  placed.  It 
delays  the  healing  of  the  wound,  it  may  cause  an  unsightly  scar,  and  it 
provides  a  moist,  warm,  nutrient  track  along  which  infection  may  readily 
propagate  until  it  reaches  the  depths  of  the  wound.  As  all  the  oozing 
which  is  going  to  occur  usually  ceases  by  twenty-four  or  forty-eight  hours 
after  the  operation,  the  drainage  in  aseptic  incised  wounds  should  always 
be  out  by  this  time.  At  the  time  of  the  operation  one  or  two  "  provisional " 
sutures  of  silkworm  gut  should  have  been  taken  at  the  site  of  drainage, 
with  long  ends  tied  loosely.  These  now  may  be  firmly  tied,  the  drainage 
being  out,  approximating  the  separated  edges  and  encouraging  primary 
union.  Aseptic  drained  wounds  should  be  dressed  as  little  as  possible, 
for  the  possibility  for  infection  from  without  is  great.  The  best  rule  is, 
leave  the  dressing  alone  until  twenty-four  or  forty-eight  hours  have 
passed,  depending  on  the  amount  of  ooze  expected;  then  dress,  remov- 
ing wick,  and  tying  the  provisional  sutures.  Put  on  a  clean  sterile 
dressing  and  leave  undisturbed  until  the  stitches  are  due. 

In  the  abdomen  the  indications  for  drainage  are  practically  the 
same — the  serous  ooze  from  wounded  surfaces    and  the  secretion  of 


WHEN   TO   DRAIN  215 

the  irritated  peritoneum;  the  bloody  ooze  from  raw  areas  and  the 
bleeding  from  fine  vessels  which  could  not  be  found  or  tied  but  have 
to  be  controlled  by  pressure;   and  infected  or  seropurulent  fluid. 

When  the  normal  peritoneum  is  handled  or  irritated,  as  in  the  manip- 
ulations of  any  intra-abdominal  operation,  it  secretes  a  serous  fluid, 
the  amount  of  which  varies  in  proportion  to  the  trauma  and  the  extent 
of  surface  which  has  been  injured.  For  instance,  after  an  easy  ap- 
pendectomy the  amount  of  exudation  will  be  so  limited  that  it  will  be 
absorbed  by  the  contiguous  healthy  peritoneum  about  as  fast  as  it  is 
formed;  if  the  appendix  has  been  found  buried,  or  if  many  adhesions 
have  had  to  be  separated,  the  advisability  of  leaving  in  a  drain  will  be 
decided  by  the  condition  of  the  patient  and  the  experience  of  the  operator ; 
if  there  has  been  extensive  overhauling  of  tissues,  and  considerable  areas 
of  raw  surfaces  have  been  left  behind,  as  after  a  double  salpingo-hysterec- 
tomy,  there  may  be  secreted  a  very  considerable  quantity  of  fluid — faster 
than  the  peritoneum  with  which  it  comes  in  contact  can  absorb  it.  As 
a  result,  it  tends  to  gravitate,  together  with  whatever  blood  may  have 
oozed  out  through  the  lines  of  sutures,  into  Douglas'  pouch,  and  here 
it  is  extremely  likely  to  stagnate  and  become  infected,  either  by  decom- 
position as  a  result  of  the  growth  of  bacteria  introduced  during  the  opera- 
tion, or,  as  is  likely,  from  contamination  through  the  wall  of  the  intestine. 
To  prevent  the  occurrence  of  peritonitis  any  case  in  which  we  appre- 
hend that  there  will  be  considerable  exudation  should  be  drained, 
especially  if  there  is  any  possibility  of  this  fluid  becoming  infected 
through  the  escape  of  nonsterile  fluid  or  pus  into  the  abdominal  cavity, 
or  through  the  opening  of  viscera.  "And  in  any  case  of  doubt, ^"^  says 
Greig- Smith,  "it  is  wise  to  drain." 

It  is  not  commonly  that  the  abdomen  will  have  to  be  closed  without 
the  assurance  that  all  hemorrhage  has  ceased.  Occasionally,  however, 
this  happens,  after  long  and  extensive  operations  in  the  female  pelvis, 
after  operations  for  abdominal  trauma,  such  as  rupture  of  the  spleen, 
and  in  operations  for  postoperative  hemorrhage.  The  customary  pro- 
cedure, in  case  of  actual  hemorrhage,  is  to  pack  tightly  with  gauze,  so 
as  to  stop  the  bleeding  by  pressure;  if  there  is  slow  capillary  hemor- 
rhage or  oozing,  a  glass  or  rubber  tube  is  left  in,  through  which,  by  capil- 
lary attraction  or  the  use  of  an  aspirator,  the  blood  and  serum  are  removed 
so  as  to  keep  the  abdomen  dry  and  encourage  clotting. 

In  case  of  general  peritoneal  infection  the  object  of  drainage,  whether 
by  tube  or  gauze,  is  (i)  to  allow  free  escape  of  septic  fluids,  the  intra- 
abdominal pressure  being  higher  than  the  atmospheric;  (2)  to  encourage 
the  escape  of  these  fluids  by  gravity  and  by  capillary  siphonage;    and 


2l6  TREATMENT    OF    THE    OPERATIVE    WOUND 

(3)  to  a  greater  or  less  extent  to  excite  by  local  irritation  an  increased 
peritoneal  secretion,  both  for  the  purpose  of  diluting  and  of  antagoniz- 
ing the  infective  matter.  If  the  sepsis  is  local,  drainage  has,  in  addition 
to  these  functions,  the  purpose  of  keeping  the  intestines  away  from 
the  infected  focus,  and  of  deliberately  exciting  the  growth  of  adhesions 
to  form  a  wall  surrounding  the  focus  and  excluding  it  from  the  rest  of  the 
abdominal  cavity. 

The  oldest  form  of  abdominal  drainage  is  the  glass  tube.  This, 
in  its  simplest  form,  is  a  cylinder  about  twice  the  diameter  of  a  lead- 
pencil  and  two-thirds  as  long,  with  carefully  rounded  edges,  and  near 
its  proximal  end  a  collar  to  prevent  its  slipping  through  the  wound  into 
the  abdomen,  and  near  its  distal  end  two  or  three  fenestra.  Nowadays, 
in  America  at  least,  the  use  of  the  glass  tube  seems  to  be  going  out  of 
fashion,  although  it  clearly  has  some  advantages.  It  excites  the  forma- 
tion of  no  adhesions  and  its  lumen  is  always  patent.  The  discharge 
of  fluid  through  it  depends  upon  intra-abdominal  pressure  and  the 
capillary  attraction  of  the  dressing.  It  is  usually  wise  to  reinforce  this 
action  by  means  of  gauze  inserted  through  the  tube  or  by  means  of 
the  "sucker."  Either  method  is  practically  ideal  for  aseptic  cases. 
With  a  gauze  wick  run  through  the  tube  we  have  all  the  advantages  of 
continuous  capillary  drainage  exerted  just  where  it  is  applied,  and 
nowhere  else,  without  exciting  adhesions.  The  drainage  action  cannot 
be  shut  off  by  a  pinching  of  the  gauze  wick  by  the  abdominal  wound,  and 
if  the  serum  clots  in  the  wick,  a  new  one  can  readily  be  inserted. 

A  "sucker"  is  a  sterilizable  glass  syringe  with  firm  valve  packing 
having  a  piece  of  rubber  tubing  or  a  catheter  attached,  long  enough  to 
reach  through  the  drainage-tube  to  the  depths  of  the  wound.  The 
syringe  is  worked  reversed,  so  as  to  exhaust  the  drainage-tube  of  the 
blood  or  fluid  it  contains.  In  case  of  hemorrhage  the  sucker  should 
be  employed  often  enough  to  keep  the  peritoneum  dry — every  few 
minutes  if  necessary.  If  the  end  and  the  fenestra  of  the  tube  are 
blocked  by  opposing  omentum  or  bowel,  the  tube  should  be  pulled  out 
a  bit  and  slightly  rotated.  If  the  fluids  are  thick,  or  if  they  clot  within  the 
tube,  the  "sucker"  will  have  to  be  used. 

As  with  all  drains,  the  glass  tube  should  be  removed  as  soon  as  the 
case  will  allow,  partly  on  account  of -the  great  risk  of  infecting  the  peri- 
toneal cavity  from  without  through  the  drainage  tract,  and  partly  on 
account  of  the  resulting  malapposition  of  muscle  and  fascia  in  the  scar, 
and  the  consequent  liability  to  postoperative  hernia.  If  the  tube  has  been 
left  in  for  hemorrhage  or  oozing,  it  can,  as  a  rule,  be  safely  removed 
after  twenty-four  to  forty-eight  hours,  or  as  soon  as  the  discharge  ceases; 


HOW    TO    DRAIN  217 

if  for  suppuration,  it  should  be  left  in  two  to  four  days  and  then  re- 
placed by  a  rubber  tube  or  gauze  wick.  The  glass  tube  conies  out,  as 
a  rule,  more  easily  than  any  other  form  of  drainage.  Before  with- 
drawing it  should  be  loosened,  if  straight,  by  twisting  or  rotating  it 
slightly.  In  pulling  it  out  one  must  be  careful  that  no  omentum  is 
caught  in  the  fenestra;  sometimes  small  tabs  will  become  incarcerated 
within  the  tube  and  they  will  have  to  be  tied  off.  In  using  the  glass 
tube  care  must  be  taken  that  the  tube  does  not  slip  in  through  the  wound 
and  be  lost.  Glass  tubes  have  been  known  to  break  while  the 
patient  is  vomiting  or  straining.  The  swathe  and  dressing  should  be 
adjusted  carefully,  so  that  the  tube  is  not  forced  in  hard  enough  that 
by  pressure  on  the  intestinal  wall  it  may  cause  perforation  or  partial 
obstruction. 

In  applying  the  gauze  dressing,  as  in  all  abdominal  drainage,  whether 
depending  upon  a  tube  or  upon  capillary  attraction,  the  principles 
governing  the  siphonage  of  fluids  should  not  be  forgotten.  Other  things 
being  equal,  the  greater  the  mass  of  gauze  outside  the  wound,  the  greater 
will  be  the  capillary  attraction,  and  the  lower  this  gauze  is  massed 
below  the  level  of  the  fluid  to  be  exhausted,  the  greater  will  be  the  force 
of  the  siphonage  exerted.  In  other  words,  the  gauze  dressing  should 
be  bulky,  and  should  be  carried  well  down  the  patient's  side  and  even 
part  way  under  his  back.  If  it  is  moistened  with  sterile  salt  solution, 
its  efficiency  is  increased. 

The  rubber  tube  was  first  introduced  as  a  substitute  for  the  glass 
tube.  It  is  less  dangerous  mechanically,  inasmuch  as  it  cannot  break, 
and  there  is  little  danger  of  its  causing  perforation  of  the  bowel  by 
pressure.  It  is  used  generally  for  draining  particular  cavities,  such  as 
the  pleural,  and  hollow  viscera — the  bladder  and  the  gall-bladder.  In 
the  abdominal  cavity  its  use  is  practically  limited  to  diffuse  peritonitis, 
and  here  it  is  invaluable,  being  employed  in  the  abdominal  wound,  in 
the  flank,  and  through  the  vagina.  It  should  be  thoroughly  sterile  and 
comparatively  fresh,  othenvise  it  is  liable  to  decompose  and  soften  if 
kept  in  an  antiseptic  solution,  or  else  become  stiff  and  brittle  if  kept  dry. 
The  lumen  may  be  of  any  size  to  suit  the  individual  case;  it  should  be 
fairly  thick-walled,  otherwise  the  lumen  is  likely  to  be  choked  off  by 
the  pressure  of  the  abdominal  jnuscles  as  it  passes  through  the  wound, 
especially  in  the  gridiron  or  right  rectus  incision.  The  ends  should 
be  clean  cut,  and  there  should  be  fenestra  provided  at  the  end  to  be  in- 
serted, so  that  if  one  opening  becomes  occluded,  valve  fashion,  by  a 
piece  of  intestine  or  omentum,  others  will  be  provided.  If  the  tube  is 
fenestrated  its  entire  length,  it  will  interfere  with  the  siphonage,  and 


2l8  TREATMENT    OE    THE    OPERATIVE    WOUND 

will  allow  of  the  spreading  of  infected  fluid  from  one  focus  among 
the  intestines  and  between  the  layers  of  the  abdominal  wall. 

Gau^e  is  used  as  packing  to  stop  hemorrhage,  as  a  drain  to  draw 
off  serous  and  seropurulent  fluids  by  capillary  action/  and  as  a  local 
irritant  to  set  up  a  plastic  peritonitis  and  so  wall  off  a  localized  septic 
focus  from  the  rest  of  the  abdominal  cavity.  When  used  to  stop  hemor- 
rhagic oozing  by  pressure,  it  should  be  out  by  forty-eight  hours.  If 
during  the  withdrawal  fresh  blood  appears,  part  of  the  packing  may  be 
left  in,  to  be  removed  twenty-four  hours  later. 

Gauze  excites  a  proliferation  of  every  peritoneal  surface  with  which 
it  comes  in  contact.  Granulation  tissue  grows  into  its  meshes,  making 
it  oftentimes  extremely  difficult  and  extremely  painful  to  remove  on 
account  of  the  tearing  of  these  granulations,  which  sometimes  bleed 
considerably.  Before  forty-eight  hours  it  will  be  found  to  come  away 
comparatively  easily,  because  by  this  time  the  proliferation  has  not 
gone  very  far.  After  four  to  six  days  from  the  operation  the  granula- 
tions soften  down  and  retrogress  under  the  influence  of  the  secretion 
which  has  backed  up  behind  the  wick,  and  at  this  stage  it  will  come 
out  easily  as  at  first.  If  it  is  left  in  so  long,  however,  it  is  likely  to  be 
followed  by  a  considerable  gush  of  seropurulent  fluid,  which  has  col- 
lected, and  may  be  under  some  pressure,  between  the  wick  and  the 
abscess  wall  it  has  created,  for  plain  gauze  wicking  ceases  to  serve 
as  capillary  drainage  after  about  forty-eight  hours;  serum  inspissates 
within  its  meshes  and  clogs  its  action,  so  that  after  forty-eight  hours 
it  may  act  simply  as  a  plug;  medicated  gauze  goes  out  of  action  so  far 
as  capillary  drainage  goes  earlier  than  plain.  The  rule  with  gauze 
drainage,  then,  is  to  remove  it  within  forty-eight  hours,  or  not  until  four 
days. 

If  the  patient  is  nervous  and  dreads  the  pain  that  the  removal  of  a 
tight  wick  will  cause,  it  is  best  to  give  gas,  ethyl  chlorid,  or  chloroform. 

^  Royster  (The  Inconsistencies  in  Gauze  Pack,  Ann.  Surg.,  1908,  xlviii,  219)  states 
that  the  introduction  of  gauze  into  surgical  practice  is  less  of  a  blessing  than  it  was  first 
thought  to  have  been.  Instead  of  facilitating  the  removal  of  wound  products,  gauze  acts 
as  a  successful  stopper  to  the  outlet  of  the  wound  and  impedes  the  natural  outflow  from  it. 
When  intended  for  a  drain,  gauze  should'  be  inserted  after  the  manner  of  a  lamp-wick — 
that  is  to  say,  it  should  maintain  the  patency  of  the  wound  orifice  without  either  clogging 
the  cavity  or  obstructing  the  opening.  When  used  for  hemorrhage,  it  should  be  packed 
in  like  wadding  with  a  ram-rod.  The  edges  of  the  wound  begin  to  contract  around  it  and 
become  adherent  to  it  in  a  few  hours.  Unless  the  secretion  be  very  thin,  no  capillarity 
will  be  present.  There  is  a  field  for  the  use  of  gauze  in  packing  sinuses,  fistulae,  and 
granulating  wounds  so  that  healing  may  take  place  slowly  from  the  bottom.  Even  here, 
however,  the  pack  should  be  loosely  done  and  the  gauze  preferably  saturated  with  some 
substance  which  will  prevent  sealing  of  the  wound  edges. 


REMOVAL    OF    DRAINS  219 

It  is  the  first  pull  which  is  most  painful;  if  the  adhesions  are  separated 
by  a  preliminary  jerk,  the  rest  is  apt  to  be  less  uncomfortable.  The 
wick  should  be  seized  by  forceps  or  with  the  right  hand,  while  counter- 
pressure  is  being  made  on  either  side  of  the  wound  with  the  left,  and 
rotated  or  t\visted  on  itself,  while  it  is  being  gently  withdrawn,  pulling 
first  to  one  side  and  then  to  the  other.  The  hands  should  be  sterile, 
so  that  any  omentum  which  is  being  dragged  up  into  the  wound  may  be 
replaced.  If  bright  blood  appears  on  the  gauze,  part  of  the  drain 
should  be  left  in  for  tvv^enty  four  hours  longer.  If  the  wick  is  being 
removed  early,  in  a  supposed  sterile  case,  and  pus  appears  on  the  drain, 
another  should  be  left  in  for  three  or  four  days  longer,  to  prevent  the 
infection  from  spreading  and  allow  the  focus  to  wall  off. 

When  an  infected  drainage  cavity  is  well  established  as  a  single 
cavity  without  side-pockets,  and  the  amount  of  discharge  is  only,  that 
which  might  be  expected  from  a  granulating  surface,  the  wick  is  left 
out  and  the  wound  poured  full  of  balsam  of  Peru  or  sterile  glycerin 
and  so  left.  Such  an  emollient  is  dehydrating,  stimulating,  and  slightly 
antiseptic,  and  yet  prevents  the  skin  from  closing  over  before  the  depths 
are  healed.  If  a  wound  is  draining  pus,  the  wick  should  not  be  allowed 
to  lie  upon  the  skin,  on  account  of  the  danger  of  stitch  abscesses — it 
should  be  well  wrapped  in  gauze.  If  the  wound  or  stitch  holes  tend 
to  become  red  or  macerated  from  infections  or  irritating  discharge,  dry 
the  wound  margin  and  a  zone  about  2  in.  around  it  in  all  directions 
thoroughly,  then  apply,  with  cotton  or  camel' s-hair  brush,  compound 
tincture  of  benzoin,  letting  one  layer  dry,  then  applying  another. 

Provisional  sutures  should  be  tied  only  if  the  drainage  has  been 
removed  within  the  forty-eight  hour  limit  and  there  is  no  sign  of  infec- 
tion.    For  gaping  of  the  wound  later  adhesive  straps  should  be  used. 

Vaginal  drains  should  come  out  on  the  second  or  third  day.  With 
the  patient  at  the  edge  of  the  bed,  in  the  Sims  posture,  and  a  speculum 
in  place,  the  wick  may  usually  be  removed  with  little  pain.  If  it  shows 
signs  of  the  presence  of  pus,  it  should  be  replaced  by  a  fresh  one;  other- 
wise the  vagina  is  washed  out  gently  and  is  lightly  packed  with  sterile 
gauze. 

Sometimes  a  surgeon  will  combine  one  or  more  methods  of  drainage; 
he  will  wrap  a  glass  tube  in  gauze  before  inserting  it  down  to  the  pelvis, 
he  will  wrap  a  gauze  strip  in  rubber  dam  and  call  it  a  "cigarette"  wick,^ 

^  F.  Hawkes  (Ann.  Surg.,  1909,  xlix,  192)  states  that  the  force  of  gravity  is  important  in 
draining  parts  of  the  abdominal  cavity  which  are  not  in  direct  contact  with  the  capillary ' 
drain.  A  complete  empt>'ing  of  these  other  parts  into  the  drain  should  occur  within  the  first 
twelve  or. eighteen  hours  after  operation,  for  it  is  exceedingly  doubtful  if  any  drainage  occurs 


220 


TREATMENT    OF    THE    OPERATIVE    WOUND 


or  in  a  rubber  tube  split  or  cut  spirally  (Fig.  84).     A  tube  wrapped  in 
gauze  usually  drains  freely,  both  by  capillary  action  and  internal  pressure. 


Fig.  84. — Drainage. 
A,  Split-rubber  drain;  B,  spiral  drain;  C,  fenestrated  rubber  tube;  D,  cigarette  wick. 

In  a  septic  case  the  tube  should  be  removed  in  about  forty-eight  hours 
and  the  gauze  left  in  until  the  fourth  or  sixth  day.     The  cigarette  wick 

has  the  advantage  of  being  re- 
moved painlessly  and  of  limiting 
the  irritating  effect  of  the  gauze 
to  the  area  about  the  tip.  The 
same  may  be  said  of  the  gauze 
wrapped  in  a  spiral  cut  rubber 
tube.  Either  should  be  removed 
as  any  gauze  wick.  Sometimes  a 
surgeon  will  use  for  an  appendix 
abscess  or  a  localized  peritonitis 
a  rubber  tube  and  a  half  dozen 
small  gauze  wicks.  The  small 
wicks  have  the  advantage  of  com- 
ing out  more  easily  than  the  large. 
The  tube  is  removed  on  the  second  day,  two  of  the  wicks  on  the  third, 

after  this  time,  whatever  form  of  drain  be  used,  from  the  portions  not  in  contact  mth  the 
drain.  A  loosely  rolled  cigarette  drain,  without  any  projection  whatever  of  gauze  from 
its  lower  end,  is  the  less  irritating,  and  will  drain  adjacent  regions  perfectly  for  twelve  to 
eighteen  hours  if  adhesions  have  not  formed  in  them  before  operation,  and  if  the  fluid 
to  be  drained  is  not  too  thick,  but  no  longer.  For  this  reason  the  drain  should  be  of  ade- 
quate size  and  the  patient  should  be  kept  in  the  proper  position  in  bed.  The  position  to 
be  maintained  can  be  easily  figured  out  from  the  diagrams  in  the  article  of  Dr.  R.  C. 
Coffey,  Jour.  Amer.  Med.  Assoc,  March  i6,  1907. 

Capillary  action  is  not  so  important  as  intra-abdominal  pressure.  ISIore  surgeons 
are  getting  away  from  prolonged  drainings  with  better  results.  Remove  the  drain  at  the 
first  possible  moment  and  allow  the  wound  to  heal. 


Fig.  Ss. — Drainage. 
A,  Rectal  plug,  containing  core  of  rubber  tubing; 
B,  inverted  rubber  tube  designed  for  drainage  of  large 
cavities. 


STITCH   ABSCESS 


221 


two  on  the  fourth,  and  two  on  the  fifth,  and  the  last  ones  are  replaced  by 
a  single  wick,  just  long  enough  to  keep  the  wound  edges  apart.  This  is 
practically  equivalent  to  packing  an  abscess-cavity. 

Unless  the  peritonitis  is  well  walled  off  at  the  time  of  operation,  it 
is  unwise  to  remove  any  drainage  until  the  gauze  has  caused  a  w^all  to 
form  about  it — say,  in  four  or  five  days — otherwise  pus  from  the  wick 
may  be  spread  broadcast  over  adjacent  coils  of  intestine.  In  an  early 
general  peritonitis,  where  there  are  few  or  no  adhesions  to  interfere, 
if  the  abdomen  is  left  full  of  salt  solution  and  adequate  drainage  is  pro- 
vided, currents  of  flow  are  set 
up  from  all  directions  to  the 
wicks,  which  carry  off  the  di- 
luted septic  material.  In  pa- 
tients with  sufficient  resistance 
the  infection  is  overcome  every- 
where except  about  the  wicks, 
where  the  septic  fluids  mass 
and  concentrate  themselves. 
Here,  in  due  time,  the  wicks  if 
undisturbed  create  a  wall  about 
themselves,  so  that  in  favorable 
cases  we  have,  after  a  few  days, 

practically  a  walled-off  abscess  to  treat  at  each  drainage  site.  If  the 
gauze  drainage  in  these  cases  is  disturbed  too  early,  the  results  may  be 
disastrous  from  a  tearing  down  of  adhesions  and  a  distribution  of  con- 
centrated pus. 

STITCH  ABSCESS 

Stitch  abscesses  are  most  apt  to  occur  after  abdominal  operations. 
They  may  be  superficial,  that  is,  running  in  the  suture  track  of  a  skin 
suture,  or  deep,  in  case  the  wound  has  been  sewed  up  in  layers,  from 
infection  about  a  buried  suture  or  ligature.  The  source  of  infection  in 
practically  all  cases  of  deep  abscess  is  unclean  catgut.  Surface  suture 
holes  may  become  infected  from  unclean  suture  material,  from  bacteria 
in  or  on  the  skin  or  on  the  surgeon's  hands,  from  strangulation  of  the 
tissues  by  tying  sutures  too  tightly,  or  from  tension  resulting  under 
the  swelling  incident  on  normal  repair.  Abscess  in  the  incision  de- 
velops secondarily  from  the  infection  of  coagulated  blood  or  serum 
collected  between  poorly  approximated  planes  of  tissue,  from  an  untied 
vessel,  or  a  vessel  pierced  unwittingly  in  sewing  up  the  skin,  or  as  a 
result  of  bruising  of  the  edges  of  the  incision  by  stretching  or  rough 
retraction.     An  abscess  may  develop  either  in  the  incision  or  in  the 


Fig.  86. — Mikulicz  Tampon  for  Peritoneal  Drain- 
age. 


222  TREATMENT    OF    THE    OPERATIVE    WOUND 

suture  track  from  contact  with  the  drainage  in  infected  cases.  The 
liability  to  these  occurrences  is  greater  in  the  presence  of  a  thick,  fatty, 
abdominal  wall.  If  it  arises  from  an  infected  hematoma,  the  first  dis- 
charges have  the  chocolate  color  of  decomposed  blood. 

Ordinarily,  if  the  pus  forms  in  the  loose  subcutaneous  tissues,  it 
either  finds  its  way  to  the  skin  surface  along  a  suture  track,  or  else 
it  burrows  its  way  to  the  incision  line  and  discharges  through  this. 
If  the  infection  arises  below  the  anterior  sheath  of  the  rectus  in  an 
abdominal  incision  closed  in  layers,  either  from  buried  catgut  or  from 
a  hematoma  collected  between  layers,  the  pus  will  be  under  considerable 
tension.  Unless  it  finds  its  way  through  the  suture  line  in  the  rectus, 
or  unless  a  way  for  discharge  is  made  for  it,  it  will  burrow  about  in  the 
abdominal  wall  between  the  fascial  planes  or  else  burst  into  the  peri- 
toneal cavity.  It  is  a  wise  precaution  in  any  patient  with  a  thick  fatty 
layer  in  the  abdominal  wall  and  a  long  incision  to  insert  a  strip  of 
rubber  dam  obliquely  down  to  the  rectus  sheath  from  the  lower  end  of 
the  wound.  When  this  is  taken  out  after  forty-eight  hours,  it  will  be 
followed  by  a  copious  secretion  of  golden-yellow  serum,  representing 
the  accumulation  of  the  exudate  from  the  entire  length  of  the  incision. 
The  provisional  suture  may  be  tied,  especial  care  being  taken  that  no 
infection  is  introduced  at  this  dressing.  If  the  sepsis  arises  from  an 
unclean  catgut  ligature,  and  the  catgut  does  not  dissolve  or  find  its 
way  out,  a  so-called  ligature-sinus  will  result,  which  may  persist  for 
months,  or  a  residual  abscess  gradually  develop,  and  not  give  rise  to 
symptoms  until  months  after  the  operation. 

If  after  a  celiotomy  closed  without  drainage  the  temperature-curve 
has  not  reached  normal  by  the  fourth  day,  or  if,  having  dropped  to 
normal  once,  it  rises  again  on  the  fourth  day  or  after,  and  no  reasonable 
cause  can  be  assigned,  the  wound  should  be  inspected  at  once.  If  on 
the  fourth  day  or  after  the  patient  on  turning  in  bed,  on  coughing  or 
vomiting,  feels  pain  in  the  region  of  the  wound,  the  incision  should  be 
examined.  Usually  there  will  be  both  pain  and  fever  to  some  degree; 
if  the  infection  is  of  any  virulence,  there  will  also  be  an  increase  in  the 
pulse-rate'  and  a  leukocytosis.  The  presence  of  a  high  white  count 
will  be  of  considerable  aid  in  making  the  diagnosis  of  deep  suppuration 
in  the  abdominal  wound.  Sometimes,  however,  the  patient  will  ex- 
hibit no  fever  and  complain  of  no  discomfort,  and  yet  when  the  sutures 
are  removed,  one  or  more  will  be  followed  by  a  few  drops  of  thin  pus, 
or  the  dressing  may  show  a  narrow  line  of  pus  corresponding  to  the 
incision  and  the  wound  itself  be  healthy  and  healing,  apparently 
having  spontaneously  overcome  a  low-grade  infection.     Nevertheless, 


INFECTION    OF    THE   WOUND  223 

it  is  of  extreme  importance  to  make  the  diagnosis  and  institute  treat- 
ment early,  for  with  extensive  suppuration  there  is  ahvays  great  delay 
in  healing  and  the  scar  is  wide,  unsightly,  and  thin,  with  a  pronounced 
tendency  to  stretch  and  give  rise  to  a  postoperative  hernia.  In  dressing 
wounds  with  stitch  abscess,  aseptic  precautions  should  be  as  carefully 
observed  as  if  the  wound  were  healing  aseptically,  for  otherwise  new 
types  of  organisms  may  be  introduced,  which  find  a  fruitful  soil  for 
growth  in  the  discharges  and  may  result  in  a  more  serious  type  of  in- 
fection. 

When,  as  a  result  of  tension,  there  is  found  an  area  of  redness  about 
one  or  more  sutures,  painful  when  pressed  with  a  probe,  and  there  is 
no  pus,  simply  cutting  the  suture  and  leaving  it  in  situ  will  often  abort 
a  stitch  abscess.  Cutting  relieves  the  tension  causing  the  inflammation, 
and  the  suture  serves  as  a  drain  for  any  exuded  serum.  If  the  process 
has  gone  so  far  before  it  is  seen  that  pus  has  already  collected,  or  if 
pus  exudes  as  a  result  of  gentle  pressure,  remove  the  stitch  on  the  side 
of  the  abscess;  if  it  is  only  on  one  side,  swab  with  alcohol  and  dress  with 
a  sterile  moist  alcohol  pad,  taking  care  not  to  infect  other  sutures. 
Another  method  is  to  press  out  the  pus  and  fill  the  stitch  abscess  cavity 
with  iodoform  powder.  If  it  is  necessary  to  remove  neighboring  stitches 
so  as  to  relieve  all  tension,  do  so,  for  if  infected  serum  is  subjected  to 
tension,  which  increases  with  inflammation,  it  finds  its  way  along  the 
lines  of  least  resistance,  not  only  into  the  lymphatics  and  veins,  but 
between  the  planes  of  fascia,  so  that  the  wound  and  all  the  adjacent 
structures  may  be  dissected  apart.  If  a  stitch  abscess  or  two  can  be  re- 
lieved before  it  has  spread  to  neighboring  suture  holes  or  to  the  incision 
itself,  the  temperature  will  probably  fall. 

If  there  is  reddening  alongside  the  entire  incision,  it  means  that  the 
incision  itself  is  infected.  In  this  case  sufficient  sutures  should  be 
removed,  whether  infected  or  not,  to  allow  of  a  separation  of  the  wound 
edges.  The  lips  of  the  wound  should  be  gently  drawn  apart,  and  any 
encapsulated  pus  or  serum  released.  If  none  appear,  the  wound  must  be 
gently  dissected  open  with  the  flat  end  of  the  probe,  wherever  there  are 
signs  of  inflanmiation,  until  pus  is  found  if  present.  In  any  case  a 
wick,  consisting  of  a  few  threads  or  a  selvedge  of  sterile  gauze,  should 
be  introduced  to  the  depths  to  prevent  an  immediate  resealing  of  the 
w'ound. 

Sometimes  there  is  little  reaction,  either  general  or  local,  to  stitch 
infection,  and  when  the  wound  is  examined,  the  process  has  so  far  de- 
veloped that  the  incision  is  red  and  bulging  with,  if  not  discharging, 
pus,  and  all  or  most  of  the  stitch  holes  are  surrounded  by  red  and  shiny 


224  TREATMENT   OF   THE    OPERATIVE   WOUND 

areolae  and  are  oozing  a  seropurulent  fluid.  Under  these  circumstances 
radical  action  must  not  be  delayed.  All  the  stitches  are  to  be  removed, 
and  reliance  placed  upon  adhesive  straps  laid  on  over  the  inner  dressing 
to  hold  the  wound  edges  together.  The  wound  must  be  separated  and 
all  pus  and  crusts  swabbed  away.  If  the  condition  justiiies  the  pro- 
cedure, an  irrigation,  given  very  gently  and  under  low  pressure  with 
sterile  normal  salt  solution  or  weak  corrosive  sublimate,  is  efl&cient  in 
washing  out  the  free  pus  in  the  wound.  Preference  should  be  given 
to  the  normal  saline,  as  the  corrosive  forms  a  filmy  coagulum  of  the 
albumin  in  the  exudation  which  covers  the  entire  surface.  A  female 
catheter  of  glass  makes  a  good  irrigating  tip,  which  can  be  inserted 
to  the  bottom  of  the  wound.  After  this,  small  gauze  drains  or  a  fine 
rubber  tube  should  be  inserted,  and  a  sterile  pad  of  gauze,  wrung  out 
in  hot  creolin  or  carbolic  solution,  applied  over  the  wound,  or  a  hot 
sterile  solution  of  salt,  sodium  citrate,  and  water  (which  we  will  con- 
sider later).  If  the  wound  is  on  the  arm  or  leg,  the  entire  limb  may 
be  immersed  in  a  basin  and  soaked.  Over  the  dressing  are  placed 
straps  which  are  to  hold  the  wound  together,  being  careful  that  the 
strips  are  long  enough  so  that  they  will  not  be  loosened  by  the  moisture 
of  the  overlying  fomentations.  These  are  important,  because  the 
moist  dressings  tend  to  cause  the  incision  to  open  up  if  many  sutures 
are  removed.  .  Then  comes  the  hot  poultice  or  fomentation.  This 
should  be  thick  and  absorbent  and  should  be  renewed  hot  every  two 
hours.  Creolin,  chlorinated  soda,  or  corrosive  may  be  employed,  and 
it  should  be  covered  with  oiled  silk  or  paper  to  keep  in  the  moisture 
and  sheet-wadding  to  preserve  the  warmth.  As  soon  as  the  sepsis  is 
apparently  under  control,  the  bulk  and  frequency  of  the  dressings  may 
be  decreased,  the  drainage  gradually  diminished  and  discarded,  and 
the  edges  more  closely  approximated  by  the  adhesive. 


CHAPTER  XXIV 

TREATMENT  OF  SEPTIC  WOUNDS:  SOAKS,  POULTICES? 
HYPEREMIA,  PASSIVE  AND  ACTIVE 

An  aseptic  wound  should  be  disturbed  as  infrequently  as  the  nature 
of  things  will  allow;  septic  wounds,  on  the  other  hand,  must  be  dressed 
often.  An  abscess  or  a  cellulitis  is  to  be  considered  as  a  breeding-place 
for  bacteria,  which  may  find  their  way  into  the  systemic  circulation  by 
way  of  the  lymphatics  or  blood-vessels  and  give  rise  to  pyemia,  and  as 
a  center  for  the  elaboration  of  toxins,  which,  being  absorbed,  may  cause 
septicemia.  At  the  same  time,  a  localized  septic  process  may  grow 
by  extension,  as  between  planes  of  fascia,  and  along  lymphatic  channels, 
in  the  form  of  l}Tiiphangitis,  and  by  implantation  of  septic  material,  on 
the  external  surface,  in  glands,  etc.  Treatment,  generally  speaking, 
of  septic  conditions  after  operation  should  be  directed  toward  combat- 
ing the  local  septic  process,  preventing  extension,  and  toward  main- 
taining or  increasing  the  resisting  power  of  the  patient. 

The  fundamental  principles  of  the  local  treatment  of  septic  proc- 
esses are  rest  and  drainage.  It  is  essential  that  any  infected  wound 
be  laid  open  sufficiently  to  insure  a  free  exit  for  all  infected  secretions 
or  pus.  Whether  this  can  be  accomplished  without  the  use  of  drainage 
gauze  or  tubing  will  depend  upon  the  nature  of  the  case,  but,  in  any 
event,  it  is  better  to  err  in  the  direction  of  oversufficient  drainage.  The 
skin  wound  over  any  septic  inflammatory  process  should  be  amply 
large  to  allow  of  access  to  all  parts  of  the  infected  area;  pockets  contain- 
ing pus  or  infected  serum  if  found  should  be  broken  open,  and  they 
should  be  kept  open  by  means  of  adequate  drainage.  If  a  pocket  is 
deep-lying,  there  is  nothing  so  good  as  a  piece  of  thick-walled  rubber 
tubing,  wfth  windows  cut  in  it,  or  even  a  fenestrated  tube  of  glass.  If 
there  are  two  skin  wounds,  a  tube  entering  at  one  wound  and  making 
its  exit  at  the  other — so-called  "through  and  through"  drainage — allows 
in  a  most  efficient  manner  for  the  carrying  off  of  infected  matter  as  well 
as  for  washing  out  the  depths  by  means  of  a  syringe  and  some  anti- 
septic lotion. 

Smaller  and  well-localized  processes,  in  places  especially  where  the 
extent  and  sightliness  of  the  scar  will  necessarily  be  considered,  may 
often  adequately  drain  themselves  if  a  strip  of  dental  rubber  be  inserted 

15  «  225 


226  TREATMENT    OF    SEPTIC   WOUNDS 

in  the  wound  to  prevent  its  edges  from  adhering.  Gauze  drainage 
should  be  replaced  before  its  capillary  action  has  been  destroyed,  which 
usually  occurs  within  forty-eight  hours. 

The  principle  of  rest  in  the  treatment  of  wounds,  which  was  so 
clearly  formulated  by  Hilton  in  his  classic  work  on  Rest  and  Pain,  is 
of  as  much  importance  in  septic  as  in  aseptic  healing.  An  apprecia- 
tion of  the  pathology  of  septic  processes  in  general  will  bring  one  to 
feel  keenly  the  importance  of  the  maintenance  of  rest  in  the  affected 
part.  If  the  entire  organism  is  at  ease,  mentally  and  physically,  the 
patient's  power  of  resistance  is  allowed  to  work  at  its  best  against  the 
infection.  Rest  of  the  part  involved  is  important  also  mechanically  in 
the  prevention  of  extension  of  the  local  process  and  to  lessen  pain.  In 
some  cases  it  will  be  important  to  splint  the  part;  for  instance,  in  a 
case  of  infected  compound  fracture  or  infection  involving  tendon- 
sheaths.  A  splint  can  be  devised  of  a  framework  of  wire  covered  with 
rubber  tubing,  or  of  wood  or  tin  wrapped  with  oiled  silk,  which  will  allow 
of  easy  access  to  the  wound  and  at  the  same  time  not  interfere  with  the 
application  of  soaks  or  poultices  as  may  be  indicated. 

Upon  whomsoever  devolves  the  duty  of  dressing  a  serious  septic 
wound  the  importance  of  avoiding  all  unnecessary  handling  and  of 
overcoming  the  temptation  of  twisting  and  turning  a  limb  without 
good  reason  should  be  duly  impressed.  Poultices  and  dressings  should 
be  applied  in  such  fashion  that  they  may  be  removed  with  the  least 
possible  stirring  up  of  the  affected  part.  Bandages  and  wrappings,  so 
long  as  a  patient  is  in  bed,  should  be  studiously  avoided.  A  square  of 
cloth,  partly  ripped  down  into  strips  from  the  opposite  sides  to  form 
a  many-tailed  bandage  (Figs.  67,  68,  pp.  200,  201),  can  be  readily  adapted 
to  almost  any  part  or  surface,  and  with  its  use  a  poultice  can  be  changed 
in  a  minute,  practically  without  disturbing  the  patient  in  the  least. 

The  most  important  therapeutic  force  which  we  can  enlist  in  our 
efforts  at  combating  a  local  septic  process  is  hyperemia,  active  or  pas- 
sive. Active  hyperemia  is  usually  obtained  by  the  employment  of  heat; 
passive  hyperemia,  by  the  methods  with  which  we  have  become  familiar 
through  the  work  of  Bier — the  rubber  bandage  and  the  suction  cup. 
Roughly  speaking,  both  depend  upon  the  maintenance  of  an  increased 
blood-supply  in  the  locality  of  the  lesion,  in  the  first  case  of  arterial,  in 
the  second  of  venous,  blood. 

Heat. — Heat  may  be  applied  dry  or  moist — dry,  by  means  of  the 
hot  chamber;  moist,  by  means  of  the  poultice  mass  or  hot  soak.  In 
postoperative  technique  the  hot  chamber  has  little  place — the  use  of 
moist  heat  is  usually  more  practicable;    in  the  form  of  the  hot  soak  it 


HEAT 


227 


provides  a  means  for  a  thorough  cleansing  of  the  wound;  in  the  form 
of  the  poultice  or  hot  fomentation  it  provides  for  the  absorption  of  the 
wound  secretions;  and  in  either  form  it  prevents  the  blocking  of  paths 
of  exit  by  the  coagulation  of  exuded  serum.  The  application  of  heat 
is  most  comforting  to  the  patient. 

Basins  have  been  designed  for  submerging  the  limbs,  and  they  are 
provided  with  covers  to  prevent  the  rapid  loss  of  heat  by  radiation. 
For  a  hand  or  foot  an  ordinary  basin  may  suffice;  on  the  body,  a  bath- 
tub may  have  to  be  used.  The  solution  may  be  of  sterile  water,  salt, 
and  citrate  (see  p.  229),  weak  corrosive  or  carbolic  solutions,  and 
creolin.  Of  these  creolin,  in  the  strength  of  about  i :  4000,  or  the 
salt  and  citrate,  is  to  be  preferred.  The  sulphonaphthol  or  creolin  is 
mildly  antiseptic,  soothing,  and  retains  the  heat;  it  is  not  poisonous 
and  does  not  coagulate  albumin.  Where  a  stronger  disinfectant  action 
is  desired,  one  can  choose  the  officinal  solution  of  chlorinated  soda,  di- 
luted about  twenty  times.  To  this  tincture  of  myrrh  may  be  advantage- 
ously added  in  small  amount,  for  the  odor  and  the  soothing  sensation 
which  it  imparts  as  well  as  for  its  antiseptic  property.  Chlorinated 
soda  is  penetrating,  does  not  crack  or  chap  the  skin  as  corrosive  subli- 
mate solution  is  apt  to  do,  and  seems  to  be  the  only  efficient  means  of 
overcoming  the  infection  with  the  Bacillus  pyocyaneus  (bacillus  of  green 
pus),which  is  so  apt  to  contaminate  a  discharging  wound  of  long  standing. 

The  basin  should  be  large  enough  to  accommodate  the  lesion  com- 
fortably and  a  considerable  margin  of  normal  tissue  on  each  side.  It 
should  be  half  filled  with  the  warm  solution  and  placed  where  it  can 
be  adjusted  to  the  position  of  the  patient.  The  dressing  should  be 
removed,  and  all  gauze  wicks  and  packing  be  withdrawn  before  the 
limb  is  placed  in  soak.  Then  hot  water  is  gradually  added  until  the 
patient  can  stand  it  no  hotter,  and  this  temperature  is  maintained  by 
further  additions  at  intervals.  The  hmb  is  allowed  to  soak  quietly 
for  twenty  minutes  to  half  an  hour;  it  is  then  removed,  any  macerated 
skin  or  debris  wiped  or  scraped  away,  the  wicks  are  reintroduced,  and 
a  poultice  of  the  same  solution  as  the  soak  is  applied,  to  remain  in  place 
for  two  to  four  hours  until  the  next  soak. 

Wherever,  owing  to  the  nature  of  things,  as  in  a  breast  abscess,  a 
hot  soak  is  impossible,  the  same. end  maybe  attained  in  a  measure  by 
the  use  of  a  hot  irrigation.  For  this  purpose  a  glass  or  a  fountain 
syringe  is  employed,  the  stream  being  directed  so  that  it  may  the  most 
advantageously  reach  the  depths  of  the  wound  and  wash  out  any  re- 
tained pus  or  shreds  of  slough  or  coagulum.  If  the  wound  is  deep,  a 
glass  female  catheter  will  make  a  good  irrigating  nozzle. 


228  TREATMENT    OF    SEPTIC   WOUNDS 

Poultices. — The  purpose  of  the  poultice  or  fomentation  is  similar 
to  that  of  the  hot  soak.  It  is  sometimes  used  to  substitute  for  the  soak, 
and  it  is  practically  always  used  where  moist  heat  is  to  be  applied  and 
the  soak  is  not  practicable.  The  poultice  should  be  absorbent,  so  as 
to  take  up  the  wound  secretions  as  soon  as  they  are  formed.  It  should 
be  mildly  antiseptic,  so  as  to  prevent  propagation  of  the  infective  bacteria 
within  its  own  mass  or  about  the  skin,  and  it  should  be  so  made  as  to 
retain  its  primary  heat  as  long  as  possible.  Many  substances  have 
been  employed  for  this  purpose,  from  the  old-fashioned  bread-and- 
butter  and  flaxseed  poultice  mass  down  to  the  modern  glycerinated 
earthy  substances,  as  well  as  gauze  saturated  with  antiseptic  solutions. 
The  advantage  of  the  semisolid  masses,  like  flaxseed  and  cataplasma 
kaolini,  is  that  they  lose  heat  very  slowly  by  radiation.     Of  the  two, 


Fig.  87. — Applying  a  Poultice. 
A  gauze  pad  is  placed  next  the  wound;  over  this  oiled  paper  or  silk  to  retain  the  moisture;  next  sheet-wad- 
ding to  retain  the  heat;  finally,  the  bandage. 

recent  experiments  have  shown  that  the  flaxseed  is  the  better  retainer 
of  heat.^ 

The  great  disadvantage  of  this  form  of  poultice  is  the  fact  of  its  non- 
absorbability.  Moreover,  the  material  is  not  antiseptic,  even  if  it  has 
been  in  itself  rendered  aseptic  by  heating,  so  that,  other  things  being 
equal,  when  moist  heat  is  to  be  applied  to  a  discharging  wound,  it  is 
usually  preferable  to  employ  fomentations  of  sterile  gauze  soaked  in 
some  antiseptic  solution.  When  desired,  however,  the  flaxseed  poul- 
tice may  be  used  if  a  moist  sterile  dressing  is  placed  between  the  wound 
and  the  poultice.  For  dressing  a  moist  gangrenous  process  a  poultice, 
half  flaxseed  and  half  pulverized  charcoal,  made  up  in  the  usual  way 
in  boiling  water,  but  with  a  dash  of  chlorinated  soda,  will  relieve  the 
pain  and  destroy  the  odor.     In  applying  poultices  or  hot  fomentations 

^  J.  D.  Pilcher,  The  Rate  of  Cooling  of  Several  Poultice  Masses,  Jour.  Amer.  Med. 
Assoc,  1909,  lii,  752. 


poultices:  weights  solution  229 

we  must  take  care  not  to  burn  the  skin.  To  prevent  this  it  may  be  well 
to  smear  the  skin  over  with  sterile  oil,  vaselin,  or  boric-acid  ointment. 

It  is  sometimes  thought  that  in  dressing  a  septic  wound  the  same 
precautions  that  are  used  in  dealing  with  aseptic  wounds  are  not  neces-^ 
sary.  This  is  not  so,  for  a  new  type  of  infection  may  find  entrance  if 
proper  care  is  not  observed,  resulting  in  a  mixed  infection  which  may 
be  more  serious  than  the  primary  condition. 

The  poultice  exerts  a  beneficent  action  upon  the  tissues  only  so 
long  as  it  is  hot.  This  is  strictly  true  of  the  semisolid  masses  of  which 
we  have  spoken.  It  is  true,  to  a  somewhat  less  extent,  in  common 
gauze  compresses,  which,  being  absorbent  and  aseptic,  may  do  some 
good  in  relieving  the  wound  of  its  discharges.  Where  we  desire,  how- 
ever, to  get  the  most  beneficent  action,  we  should  see  that  the  poultices 
are  changed  every  two,  three,  or  four  hours,  and  in  serious  cases  this 
should  be  kept  up  through  the  night  without  remission.  If  a  poultice 
is  properly  covered  with  oiled  or  waxed  paper  or  oiled  silk,  and  over 
this  is  placed  a  thick  layer  of  sheet-wadding,  the  heat  will  be  retained 
much  longer.  Each  time  the  fomentation  is  changed  the  skin  about 
the  wound  should  be  gently  wiped  clean  of  pus  and  coagulated  serum, 
and  the  wicks  and  packing  should  be  changed  frequently  enough  to 
assure  of  a  definite  capillary  action. 

In  some  cases,  where  the  process  is  not  so  diffuse  as  in  a  cellulitis, 
but  is  walled  off  like  a  local  abscess  and  is  draining  well,  it  may  be 
considered  advisable  not  to  apply  heat.  Under  these  circumstances 
it  may  be  good  practice  to  apply  simply  a  rather  thick  dressing  of  dry 
sterile  gauze,  relying  upon  its  absorbability  to  take  up  the  discharges, 
or  an  antiseptic  powder,  such  as  boric  acid  or  iodoform  or  some  of  its 
odorless  substitutes.  Frequently  the  exudate  will  coagulate  about  the 
wound  so  as  to  interfere  with  the  efficiency  of  the  drainage.  To  pre- 
vent this,  it  has  lately  become  a  custom  to  employ  sterile  gauze  which 
has  been  soaked  in  a  solution  that  is  known  to  prevent  the  coagulation 
of  exudates.  Such  a  solution  (Wright's  citrate  and  saline)  may  be  made 
up  as  follows: 

I^.    Sodii  citratis, 5; 

Sodii  chloridi 20; 

Aquas 500.- — M. 

or  for  a  recipe  for  home  treatment  write — 

I^.   Sodii  citralis 12; 

Sodii   chloridi 48.— M. 

Sig. — Teaspoonful  in  half  glass  hot  water  to  wet  dressing. 

The  dressing  should  not  be  allowed  to  become  dry. 


230  TREATMENT   OF   SEPTIC   WOUNDS 

BIER  HYPEREMIC  TREATMENT 

The  Bier  hyperemic  treatment,  which  at  present  is  much  in  vogue, 
finds  its  chief  field  of  usefulness  before  operation.  However,  it  is  de- 
clared that,  when  artificial  hyperemia  is  employed  and  ample  oudet 
for  pus  is  provided,  we  are  able  to  accomplish  with  a  small  incision 
what  otherwise  would  necessitate  extensive  incision  and  too  often  re- 
sulting disfigurement  if  not  disability.  The  treatment  is  applied  either 
in  the  form  of  a  rubber  constricting  bandage  applied  proximally  to 
the  wound  or  else  by  means  of  a  suction  cup  applied  over  the  wound. 
For  a  constricting  bandage,  the  ordinary  Martin's  rubber  bandage  or 
the  Esmarch  tourniquet  may  be  employed;  for  the  suction  cup,  an 
ordinary  cupping-glass  or  one  of  the  larger  special  apparatus  adapted 
to  the  particular  part  may  be  used.  The  rubber  bandage  should  be 
applied  so  tight  as  to  cause  venous  congestion,  but  not  tight  enough  to 
give  rise  to  pain  or  entirely  to  obliterate  the  arterial  pulse.  The  bandage 
should  be  left  in  place  for  a  period  varying  from  twenty  minutes  to  two 
hours  and  should  be  reapplied  at  intervals.  The  wound  should  be 
dressed  as  already  described. 

An  able  and  complete  exposition  of  the  method  is  presented  in  the 
volume  entitled  "Bier's  Hyperemic  Treatment,"  by  Professor  Willy 
Meyer,  of  New  York,  and  Professor  Dr.  Victor  Schmieden,  of  Berlin. 
From  this  work  I  shall  quote  freely,  with  Professor  Meyer's  permission, 
but  refer  the  reader  to  the  original  for  completeness  of  detail. 

"The  physician  who- intends  to  make  use  of  artificial  hyperemia 
means  to  increase  the  quantity  of  blood  in  a  given  diseased  part  of  the 
body,  hoping  thereby  to  obtain  beneficial  results.  The  blood-current 
accomplishes  its  task  not  only  under  normal  conditions,  but  as  soon  as 
the  body  is  invaded  by  disease  requiring  an  increase  or  decrease  of  the 
blood-current  the  circulatory  conditions  become  changed.  Every  one 
must  come  to  recognize  that  the  body  in  such  instances,  in  properly 
regulating  the  blood-current,  does  a  definite  delicate  work,  thereby 
often  preventing  or  even  curing  serious  disease. 

"  He  who  has  followed  this  train  of  thought  will  coincide  with  Bier 
that  an  inflammation — from  the  physiologic  point  of  view — does  not  in 
itself  represent  a  diseased  condition,  but  is  a  phenomenon  indicating 
the  body's  intent  to  resist, a  deleterious  invasion. 

"To  increase  this  beneficent  inflammatory  hyperemia,  resulting 
from  the  fight  of  the  living  body  against  invasion,  is  the  aim  of  Bier's 
hyperemic  treatment. 

"  By  deduction  from  this  simple  reasoning  we  are  able  to  discern  the 


BIER    HYPEREMIC    TREATMENT  23 1 

first  and  most  important  principle  underlying  Bier's  hyperemic  treatmetit, 
namely: 

"  The  blood  must  continue  to  circulate,  there  must  never  he  a  stasis  of 
the  blood.     This  rule  is  of  paramount  importance. 

"  Hitherto  it  was  considered  the  physician's  first  duty  to  fight  every 
kind  of  inflammation  since  inflammations  were  looked  upon  as  detri- 
mental. 

"Bier  teaches  just  the  opposite;  namely,  to  artificially  increase  the 
redness  swelling,  and  heat,  three  of  the  four  cardinal  symptoms  of  an 
acute  inflammation. 

"The  practical  results  obtained  with  the  hyperemic  treatment  have 
proved  the  absolute  correctness  of  the  theories  advanced  by  Bier. 

"The  fact  that  artificial  hyperemia  has  already  found  use  in  such 
a  variety  of  different  diseases  seems  to  speak  for  the  correctness  of  Bier's 
prophecy  made  some  years  ago:  'This  remedy,  used  by  nature  in  such 
a  profuse  measure,  to  combat  all  sorts  of  lesions,  is  destined  to  be  far 
more  extensively  employed  than  has  hitherto  been  attempted.' 

"  If  the  physician  is  mindful  of  the  facts  that  a  gentle  hyperemia  only  is 
required  to  produce  the  desired  effect,  at  least  in  cases  of  acute  infectious 
inflammation,  in  other  words,  that  'a  too  much'  is  absolutely  injurious, 
he  will  soon  become  convinced  that  in  Bier's  treatment  we  have  a  most 
powerful  and  efficient  remedy,  altogether  unlike  any  other  known  to  us 
before. 

"It  has  been  pointed  out  that  hyperemic  treatment  has  its  greatest 
triumphs  when  applied  prophylactically.  Only  by  an  early  and  correct 
definition  of  the  seat  and  character  of  the  inflammation  and  prompt 
resort  to  artificial  hyperemia  can  the  greatest  amount  of  good  be  ac- 
complished. Nevertheless,  in  all  instances,  whatever  pus  may  have 
formed  must  be  promptly  evacuated. 

"If  the  destructive  work  of  the  invading  bacteria  has  been  allowed 
to  go  on  unchecked,  if  thrombosis  of  the  smaller  veins  within  the  focus 
of  infection,  or  even  necrosis,  has  set  in,  nothing  in  the  world  can  save 
such  a  part.  The  utmost  that  even  the  best  of  methods  can  do  in  that 
event  is  to  assist  in  eliminating  the  infective  material  and  then  help  in 
the  reconstruction. 

"While  hyperemic  treatment  is  not  a  panacea,  it  is  a  powerful 
therapeutic  agent  on  a  physical  basis,  an  agent  which  has  its  indications 
and  dosage  the  same  as  any  other  remedy.  There  is  much  to  learn 
about  it  yet. 

"  It  must  be  remembered,  however,  that  hyperemic  treatment  in  acute 
diseases  requires  more  time  and  attention  than  radical  work  with  the 


232  TREATMENT    OF    SEPTIC    WOUNDS 

knife,  chisel,  and  saw.  A  busy  man  cannot  alone  undertake  the  treat- 
ment of  many  such  cases;  he  needs  trained  assistants  in  private  as  well 
as  hospital  work. 

"There  are  three  methods  by  which  hyperemia  may  be  produced: 
(i)  By  means  of  an  elastic  bandage  or  band;  (2)  by  means  of  cupping- 
glasses;  (3)  by  means  of  hot  air. 

"  (i)  and  (2)  produce  a  passive  or  venous  hyperemia,  (3)  an  active 
or  arterial  hyperemia. 

"Retarding  the  return  of  blood  to  the  heart  by  compressing  the 
veins  at  the  most  convenient  place  between  the  focus  of  inflammation 
and  the  heart,  with  the  help  of  an  elastic  bandage  or  band,  represents 
the  old  and  typical  method  of  producing  artificial  hyperemia.  The 
Germans  call  this  '  Stauungs-hyperamie ' — a  term  prescribing  cause  as 
well  as  effect."  Some  variety  of  this  method  has  been  in  traditional 
use  by  the  country  people  in  Germany  for  an  indefinite  time  past. 

"This  obstructive  hyperemia,  when  produced  by  means  of  the  elastic 
bandage,  can  be  employed  only  in  diseases  of  the  head,  scrotum,  testicles, 
and  the  extremities. 

"Where  hyperemia  by  means  of  elastic  compression  is  not  feasible, 
it  can  be  produced  by  suction.  This  method  is  used  upon  the  breast, 
back,  spine,  pelvis,  and  the  surface  of  the  whole  body  whenever  a  local- 
ized acute  infection  or  an  open  wound  (sinus,  granulation,  etc.)  is 
present.  For  this  purpose,  cupping-glasses  of  various  size  and  shape 
are  employed. 

"Hot  air  is  generated  in  wooden  or  metal  boxes  especially  to  suit 
the  respective  case.     This  represents  an  arterial  hyperemia. 

*<  The  Blastic  Bandage.— Obstructive  hyperemia  is  produced 
by  means  of  a  soft-rubber  bandage,  same  as  is  used  for  the  production 
of  artificial  anemia  in  the  case  of  bloodless  operations  on  the  extremities. 

"In  slightly  obstructing  the  return  of  the  blood  from  the  extremity 
to  the  heart  with  the  aid  of  such  a  soft-rubber  bandage,  the  principal 
point  to  be  observed  is  that  the  circulation  be  never  entirely  interrupted. 
What  must  be  our  aim  is  to  obstruct  the  return  of  blood  from  the  ex- 
tremity under  treatment,  in  this  way  increasing  the  quantity  of  blood 
normally  contained  therein,  but  in  no  way  to  interfere  with  the  influx 
of  the  blood  through  the  artery, 

"One  must  at  all  times  be  able  to  feel  the  pulse  below  the  place 
surrounded  by  the  elastic  bandage.  It  is  not  difficult  to  find  the  proper 
measure  of  compression.  The  degree  of  obstructive  hyperemia  is  a  cor- 
rect one  if  the  patient  is  not  in  the  least  annoyed  by  the  bandage  applied. 

"  The  technique  is  correct,  if  there  is  absolutely  no  increase  of  pain 


BIER   HYPEREMIC   TREATMENT 


233 


and  if  there  is  visible  hyperemia  of  the  part  subjected  to  the  treatment. 
The  portion  distal  to  the  bandage  must  appear  bluish  or  bluish-red — 
never  white. 

"Bier  employs  a  soft-rubber  bandage,  2^  in.  wide,  which  he  winds 
around  the  limb  about  six  or  eight  times,  one  layer  overlapping  the 
other  by  about  ^  in.  In  this  manner  the  pressure  is  evenly  distributed 
over  a  comparatively  wide  area.  The  end  may  be  fastened  with  a  safety- 
pin  or  tucked  under,  or  with  tapes  which  are  stitched  on  the  bandage. 
Only  in  cases  which  require  the  bandage  to  remain  in  place  for  longer 
periods — say  twenty  to  twenty-two  hours  per  day — ^will  it  be  necessary 
or  desirable  to  first  apply  a  soft-flannel  bandage  underneath  the  rubber 


Fig.  88. — Passive  Hyperemia. 
Rubber  bandage  in  place;  note  distention  of  veins  and  cyanosis. 


bandage.  With  the  bandage  in  place,  the  distal  part  of  the  extremity 
must  feel' warm,  not  cold.  Every  focus  of  acute  inflammation  subjected 
to  obstructive  hyperemia  will  quickly  show  increased  warmth.  First, 
we  notice  a  marked  redness,  then  heat  and  a  swelling.  On  seeing  the 
swelling  increase,  the  practitioner  often  becomes  frightened,  but  there 
is  no  reason  for  alarm.  According  to  Bier,  this  phenomenon  is  to  be 
looked  upon  as  a  welcome,  salubrious  reaction. 

"The  first  effect  is  the  diminution  of  pain,  becoming  more  and 
more  noticeable  with  the  appearance  of  the  edema. 

"The  elastic  bandage  must  always  be  placed  on  a  healthy  area 
proximally  to  the  site  of  the  disease.     It  should  never  touch  the  latter. 


234  TREATMENT    OF    SEPTIC   WOUNDS 

"All  dressings  ought  to  be  removed  while  the  elastic  bandage  is  in 
place,  in  order  to  allow  the  respective  part  to  swell  and  become  hypere- 
mic.  Wounds  or  incisions  are  covered  with  sterile  gauze,  which  is 
kept  in  place  by  a  towel  loosely  wound  around  the  same  and  fastened 
by  means  of  a  few  safety-pins. 

"  If  in  the  case  of  chronic  diseases  a  distinct  hyperemia  does  not  set 
in,  it  is  advisable  to  place  the  part  in  a  bath  as  hot  as  the  patient  can 
stand  it  for  about  ten  minutes.  This  will  cause  the  extremity  to  turn 
bright  red,  after  which  the  bandage  is  applied. 

"  Further,  obstructive  hyperemia  that  is  continued  for  several  hours 
produces  edema.  During  the  intermissions  following  the  application 
of  the  elastic  bandage  for  short  periods,  say,  from  two  to  four  hours  each 
day,  the  artificial  edema  always  becomes  absorbed. 

"  In  actually  infected  cases  the  rapid  absorption  of  this  inflammatory 
edema  is  often  followed  by  some  rise  of  temperature;  this,  however,  is 
of  short  duration  only. 

"It  should  be  stated,  as  one  of  the  most  important  rules,  that  also, 
under  hyperemic  treatment,  every  abscess  has  to  be  opened.  The 
knife  takes  care  of  the  pus;  hyperemic  treatment  fights  the  infection. 
With  the  help  of  the  hyperemic  treatment,  the  large  excisions  into  the 
abscess  cavity  heretofore  practised  can  be  dispensed  with;  often  mere 
punctures  will  suffice.  These  punctures  can  be  made  without  general 
anesthesia,  and  naturally  heal  much  more  rapidly  than  large  incised 
wounds.  Furthermore,  there  is  no  need  of  the  painful  tamponade  in 
the  course  of  the  after-treatment,  and  there  is  no  extensive  scar  forma- 
tion. 

"Experience  has  shown  that  acute  infectious  processes  require 
prolonged  application  of  hyperemic  treatment  from  twenty  to  t\venty- 
two  hours  per  day.  In  chronic  affections,  especially  those  of  tuberculous 
origin,  shorter  sittings,  say,  tv\^o  to  four  hours  a  day,  have  been  found 
sufficient. 

"  The  physician  should  at  first  apply  the  bandages  himself.  Later 
he  may  train,  in  chronic  cases  at  least,  nurse  or  relatives,  or  even  the 
patient  himself,  to  do  this,  but  he  must  never  cease  to  supervise  the 
treatment,  otherwise  mistakes  or  irregularities  in  the  technique  may 
occur  which  would  mar  the  result. 

"For  the  neck  and  head,  a  strap  of  garter  elastic,  about  f  in.  wide, 
with  a  hook  at  one  end  and  a  number  of  eyes  on  the  other,  to  allow 
for  different  degrees  of  compression,  best  answer  the  purpose.  This 
band  is  applied  around  the  neck  below  the  larynx.  It  must  never 
strangulate.     The   patient   himself   must   be   the   judge.     The   object 


BIER    APPARATUS 


235 


of  the  treatment  is  to  increase  the  quantity  of  blood  in  the  head,  but 
hyperemia  must  not  interfere  with  the  patient's  abihty  to  sleep,  eat, 
and  drink.  In  order  to  increase  obstruction,  a  piece  of  soft  felt  may 
be  slipped  under  the  bandage  at  the  site  of  the  jugular  veins. 

"For  the  testicles  a  rubber  drainage-tube  is  passed  around  the  root 
of  the  scrotum  and  the  ends  held  by  a  clamp  or  a  tied  tape. 

*'  Suction  Cups. — For  other  parts  of  the  body  suction  cups,  pro- 
perly constructed  and  applied,  have  proved  to  be  a  most  efficient  means 


Fig.  89. — Suction  Cups. 
Varieties  of  suction  cups  designed  for  various  anatomic  regions;  suction  pump;  rubber  bandage. 


of  producing  obstructive  hyperemia.  By  applied  suction  hyperemia 
it  will  be  seen  that  the  skin,  plus  underlying  tissues,  are  sucked  into 
the  hollow  of  the  glass.  This  causes  a  rush  of  blood  into  the  respec- 
tive area,  but  the  hyperemia  does  not  involve  the  surface  only;  it  also 
reaches  into  the  deeper  layers. 

"Here  again  the  first  rule  is  not  to  overdo.  The  skin  should  turn 
red  or  bluish-red,  but  never  white 

"To  be  able  to  employ  the  method  more  generally,  it  was  neces- 
sary to  have  cupping-glasses  the  shapes  which  were  adapted  to  the 


236 


TREATMENT    OF    SEPTIC    WOUNDS 


varying  contours  of  the  body  surface  (see  Figs.  89-93).  In  the 
small-sized  glasses,  suction  is  obtained  by  a  small  rubber  bulb,  which 
is  either  directly  attached  to  the  glass  or  communicates  with  it  by  means 
of  a  rubber  tube. 

"With  gentle  pressure  on  the  rubber  bulb,  the  cup  is  put  in  place 
and  the  hand  is  removed.     The  cup  will  be  found  to  adhere  to  the 


J^ 


Fig.  90. — Passive  Hyperemia  Applied  to  a  Localized  Septic  Process  by  Means  of  a  Suction  Cup. 

skin  with  just  sufficient  firmness  not  to  drop  off.  To  facilitate  air- 
tight closure  of  the  cup  upon  the  skin  it  is  well  to  spread  a  thick  layer 
of  vaselin  over  the  border.  Suction  must  never  he  too  strong  and  never 
create  pain. 

"The  vacuum  apparatus  of  larger  size  is  applied  Avith  a  suction 
pump,  which  is  inserted  in  the  end  of  the  rubber  tube  in  place  of  the 


Fig.  91. — Passive  Hyperemia. 
Suction  cup  used  over  wounds  discharging  pus. 


bulb  and  regulates  the  degree  of  hyperemia.  In  all  of  the  large-sized 
suction  glasses  and  some  of  tlie  smaller  ones,  a  three-way  stop-cock  is 
placed  in  the  tube  for  the  purpose  of  obtaining  an  air-tight  closure  of 
the  cup,  after  the  desired  degree  of  obstructive  hyperemia  has  been 
attained,  and  also  to  facilitate  their  removal. 


BIER   HYPEREMIC    TREATMENT 


237 


"In  making  use  of  this  vacuum  apparatus,  we  not  only  rely  on  the 
artificial  hyperemia  it  produces,  but  also  on  its  mechanical  effect.  If 
we  place  such  a  glass  over  a  diseased  area  which  presents  a  sinus  in  its 
middle,  the  pus,  and  with  it  bacteria,  are  aspirated  from  the  depth 
slowly  and  painlessly. 


Fig.  92. — Passive  Hyperemia. 
Large  cup  applied  to  buttock;  suction  pump,  with  stop-cock  in  tube. 

"In  thus  using  the  suction  glasses  in  the  treatment  of  suppurated 
wounds  and  fistulous  tracts,  strict  asepsis  is,  of  course,  sine  qua  non. 
After  using,  the  glasses  must  be  detached  and  boiled.  The  infection 
from  the  aspirated  pus  may  further  be  avoided  by  anointing  with 
vaselin  the  border  of  the  glass  and  also  the  immediate  neighborhood 


Fig.  93. — Passive  Hyperemia. 
Suction  cup  and  pump;  lateral  enlargement  of  cup  designed  to  collect  exuding  pus. 

of  the  wound.     This  precaution  is  especially  indicated  when  treating 
furuncles. 

"The  suction  glasses  are  applied  six  times  five  minutes  per  day, 
with  intervals  of  three  minutes  between  the  applications,  in  order  to 
give  the  edema  and  hyperemic  swelling  an  opportunity  to  disappear. 


238  TREATMENT   OF    SEPTIC   WOUNDS 

Thus  the  entire  time  of  treatment  is  three-quarters  of  an  hour  each 
day. 

"After  the  suction  glasses  of  small  size  had  been  particularly  tested 
as  to  their  value,  the  manufacture  of  stronger  bottle-shaped  vessels 
suitable  for  the  reception  of  the  entire  extremities  was  taken  up."  (For 
description  and  illustration  of  these,  see  Meyer  and  Schmieden.) 

"  (3)  Hot  Air. — Any  part  of  the  body  brought  near  a  source  emitting 
strong  heat  becomes  heated  and  turns  bright  red  or  hyperemic.  The 
hyperemia  produced  by  this  is  artificial. 

"  The  increased  supply  of  arterial  blood  to  any  part  of  the  body  favors 
absorption  of  chronic  exudates,  infiltrations,  adhesions,  etc.;  therefore, 
these  chronic  conditions,  being  the  result  of  a  previous  acute  inflamma- 
tion, are  particularly  influenced  by  hot-air  hyperemia.  This  is  also 
true  of  neuralgias  of  all  varieties. 

"Dry  hot  air  permits  the  use  of  a  very  high  degree  of  heat  without 
injury  or  pain  to  the  part.  It  is  applied  either  by  hot-air  boxes  or  ovens, 
or  by  a  hot-air  douche. 

"Most  useful  ovens  are  quadrangular,  made  of  copper  or  wood, 
inexpensive  in  construction.  The  oven  is  provided  with  a  lid  with 
openings  for  the  reception  of  the  limb.  These  openings  are  lined  with 
cuffs  of  felt  or  heavy  cloth,  which  are  fastened  around  the  lamp  by 
means  of  straps  and  buckles.  In  one  side  of  the  oven  is  an  attach- 
ment for  the  reception  of  the  chimney  of  the  lamp,  through  which  the 
current  of  hot  air  enters.  For  the  purpose  of  a  more  even  distribution 
of  the  hot-air  current  and  the  better  protection  of  the  lamp  a  board  is 
placed  inside  the  oven,  not  far  from  the  internal  aspect  of  the  opening. 
For  the  same  reason,  the  oven  must  not  be  of  too  small  size. 

"The  patient's  own  feeHng  ought  to  be  the  best  guide  for  the  proper 
temperature.  There  must  be  no  pain,  or  even  annoyance,  from  the 
heat.  If  the  temperature  is  gradually  increased,  a  surprisingly  high 
degree  of  heat  can  be  borne  by  the  patient — often  as  high  as  250°  F. 

"  It  must  be  borne  in  mind  that  great  heat  makes  the  part  less  sensi- 
tive. If  due  care  is  not  taken,  a  burn  of  the  second  degree  may  occur 
without  the  patient  knowing  it  until  after  the  sitting.  The  patient 
should  be  in  as  comfortable  a  position  as  possible  during  the  treatment. 
First,  the  extremity  is  comfortably  placed  in  the  box  and  the  opening 
closed.  Then  the  lamp  is  lighted  and  placed  underneath  the  funnel. 
When  a  comfortable  degree  of  heat  has  been  obtained,  it  must  be  the 
operator's  aim  to  continue  the  same  temperature.  After  one-half  to 
one  hour  the  light  is  extinguished,  the  lid  opened,  and  the  part  allowed 
to  cool  down.     Treatment  may  be  given  daily  or  every  other  day." 


BIER    HYPEREMIC    TREATMENT  239 

Other  References 

B.  M.  Bernheim,  Passive  Hyperemia,  Jour.  Amer.  Med.  Assoc,  1908,  1,  840. 

E.  H.  Bradford,  The  Hyperemia  Treatment  of  Congested  and  Inflamed  Tissues, 
Boston  Med.  and  Surg.  Jour.,  1906,  cliv,  671. 

E.  A.  Codman,  On  the  Bier  Treatment  of  Infected  and  Septic  Wounds  of  the  Extrem- 
ities, Boston  Med.  and  Surg.  Jour.,  1906,  civ,  434. 

Frangenheim,  Archiv  f.  klin.  Chir.,  1908,  Ixxxvii,  No.  2,  reports  extensive  ex- 
periments with  abscesses  induced  on  rabbits  and  treated  with  cupping-glasses  or 
application  of  a  constricting  band  above  the  lesion.  The  results  all  seem  to  show  that 
the  hyperemia  thus  induced  had  no  bactericidal  action,  while  infectious  processes  in  the 
bone-marrow  and  joints  were  unfavorably  influenced.  Early  or  immediate  application 
of  the  measures  to  induce  hyperemia  never  succeeded  in  preventing  the  development  of 
the  infectious  process  after  inoculation.  The  formation  of  pus  was  much  increased 
under  the  constricting  band  and  with  the  cupping-glass,  while  infiltration  in  the  vicinity 
of  the  pus  focus  was  the  rule.  Suppuration,  sequestrum  formation,  and  pigmentation 
were  much  more  pronounced  with  the  induced  hyperemia  than  without  it. 

Klapp,  Ueber  die  Behandlung  enzuendlicher  Erkrankungen  mittels  Saugapparaten. 
Munch,  med.  Woch.,  1905,  No.  16. 


CHAPTER  XXV 

SINUSES  AND  FISTULAE:    LYMPHATIC  FISTULA,  FECAL 
FISTULA,  AND  ARTIFICIAL  ANUS 

SINUSES  AND  FISTULA 

A  SINUS,  in  surgery,  is  a  long,  narrow,  hollow  tract  leading  from 
some  center  of  tissue  destruction  to  the  surface,  and  serving  as  a  means 
of  exit  for  pus  or  other  pathologic  discharges.  A  sinus  may  arise  from 
a  deep-seated  abscess  in  the  superficial  tissues,  or  within  the  abdomen 
or  pelvis,  or  from  an  osteomyelitis;  it  may  take  its  origin  from  a  foreign 
body  acting  as  either  a  source  of  irritation  or  infection,  such  as  a  loose- 
lying  ligature  of  silk  or  catgut,  or  a  piece  of  necrotic  tissue,  such  as  a 
bony  sequestrum,  or  a  sloughed-off  appendix;  and  so  long  as  the  offend- 
ing body  or  disease  remains,  the  sinus  will  persist,  although  it  may  close 
up  temporarily  at  intervals.  When  a  tract  leads  from  a  viscus,  an 
excretory  duct,  or  a  glandular  structure,  it  is  called  a  fistula,  and  is 
named  for  the  organ  or  viscus  from  which  it  leads,  as  renal,  biliary, 
vesical,  salivary,  gastric,  anal,  urethral,  lachrymal,  mammary,  etc.  If 
it  leads  from  one  viscus  to  another,  it  is  named  for  the  organs  it  connects, 
as  vesicovaginal.  A  fistula  ordinarily  serves  to  carry  off  the  normal 
secretion  or  excretion  of  the  organ  or  gland  it  drains,  and  it  will  tend 
to  close  of  its  own  accord  if  all  impediment  to  drainage  through  the 
natural  exit  is  removed. 

A  sinus  leading  from  a  superficial  abscess  is  generally  not  difficult 
to  handle,  provided  the  acute  process  has  subsided  and  there  is  no 
sequestrum,  slough  ("core"),  or  foreign  body  to  keep  up  the  suppura- 
tion. If  the  sinus  tract  is  long  and  tortuous;  if  as  a' result  of  chronic 
inflammatory  changes  its  walls  are  thickened  and  cartilaginous,  the 
process  of  healing  will  be  long  and  tedious,  even  after  the  primary 
disease  process  has  been  overcome.  A  sinus  must  be  kept  open  by 
drain  or  tube  until  the  abscess  cavity  from  which  it  takes  origin  has 
filled  in  or  become  obliterated;  if  the  cavity  is  large,  and  is  so  situated 
that  it  cannot  collapse,  as,  for  instance,  a  bone  abscess,  or  if  its  walls 
have  become  infiltrated  and  thickened  so  that  they  will  not  come  together 
and  so  obliterate  the  cavity,  it  will  have  to  fill  up  by  granulations  and 
the  process  of  scar  tissue  formation,  which  will  sometimes  be  a  matter 

240 


SINUSES    AND   FISTULA  241 

of  months.  Various  injections  are  recommended  for  the  purpose  of 
encouraging  the  growth  of  granulation  tissue,  and  among  the  best  of 
these  are  glycerin,  tincture  of  iodin,  iodoform  emulsion,  and  balsam 
of  Peru  and  castor  oil  in  equal  parts,  or  1:8.  The  use  of  a  liquefied 
bismuth-vaselin  paste  after  the  method  of  Beck  ^  has  been  followed  by 
successful  results  in  well-walled-off  cavities  where  there  is  no  danger 
from  pressure  or  absorption. 

So  long  as  a  sinus  is  discharging  pus  it  must  be  kept  wide  open,  so 
as  not  to  offer  resistance  to  the  discharge  and  thus  cause  the  pus  to 
''back  up"  and  prevent  the  cavity  from  closing  in.  Crusts  must  not  be 
allowed  to  form  at  the  mouth  of  the  sinus  and  block  the  exit  under  the 
mistaken  idea  that  the  tract  is  closing  in,  especially  if  the  abscess  is 
intra-abdominal,  for  the  pus  will  collect  within  the  abscess  cavity  and 
after  some  days  or  weeks  burst  out  again.  If  during  such  a  period  of 
quiescence,  in  the  case  of  a  pelvic  or  abdominal  abscess,  scar  tissue 
has  formed  at  the  mouth  of  the  sinus  so  as  effectually  to  block  the  exit, 
operation  may  be  necessary  to  reopen  the  accumulation,  or  the  abscess 
may  burst  into  the  abdominal  cavity  or  into  some  neighboring  viscus, 
as  the  bladder  or  rectum,  and  so  find  its  way  out. 

If  granulation  tissue  forms  about  the  mouth  of  the  sinus,  it  must  be 
kept  clipped  down  with  the  scissors  or  burnt  down  with  the  silver  nitrate 
stick,  so  as  to  cause  no  impediment  to  the  outflow.  The  former  is  the 
better  method.  Granulations,  as  a  rule,  are  insensitive.  If,  as  usually 
happens  in  sinuses  of  long  standing,  the  orifice  contracts  as  a  result  of 

^  Emil  G.  Beck  (Fistulous  Tracts,  Tuberculous  Sinuses,  and  Abscess  Cavities,  Jour. 
Amer.  Med.  Assoc,  1908,  1,  868)  recommends  the  injection  of  liquefied  bismuth-vaselin 
paste  in  old  sinuses  and  fistulas  for  curative  purposes.  He  states  that  it  is  applicable  to 
all  fistulae  or  abscess  cavities  except  intracranial  sinuses  or  biliary  fistulse,  and  those  com- 
municating with  the  urinary  bladder. 

Ochsner  (Beck's  Injection  Treatment  of  Fistulae  and  Abscesses  Following  Operation 
for  Empyema,  Jour.  Amer.  Med.  Assoc,  1909,  liii,  319)  describes  the  technique  as  fol- 
lows: Formula  i,  one  part  of  arsenic-free  subnitrate  of  bismuth,  and  two  parts  sterile 
amber  vaselrn,  has  a  lower  melting-point  than  formula  2,  which  consists  of  three  parts 
of  subnitrate  of  bismuth,  six  parts  of  amber  vaselin,  and  one  part  of  paraffin.  Formula  i 
is  used  daily,  or  every  second  day,  until  the  sinus  or  abscess  is  free  from  pus,  then  formula 
2  is  used,  at  first  every  second  day,  and  then  less  frequently.  These  mixtures  are  injected 
at  110°  to  120°  F.  by  means  of  an  ordinary  glass  syringe.  Only  just  enough  force  is  used 
to  fill  the  cavity.  The  outer  opening  is  closed  with  a  gauze  plug,  the  cavity  filling  in  rapidly. 
Symptoms  of  sepsis  readily  disappear. 

Another  formula  is — 

I^.   Bismuth  subnitrate 30  parts 

White  wax 5 

Soft  paraflin 5 

Yellow  vaselin 60       "     — M. 

16 


242  SINUSES   AND   FISTULE 

the  formation  of  scar  tissue,  it  must  be  frequently  stretched  by  inserting 
a  pair  of  scissors  closed  and  pulling  them  out  opened,  or  enlarged  by 
cutting.  If  the  sinus  is  so  situated  that  it  drains  "up  hill,"  that  is, 
if  the  abscess  cavity  is  lower  than  the  mouth  of  the  sinus,  so  that  pus 
is  likely  to  collect  in  the  ca\ity  from  force  of  gravity,  considerable  time . 
may  be  saved,  when  practicable,  by  making  a  new  incision  into  the 
cavity  at  its  most  dependent  point  and  allowing  the  old  sinus  to  close 
up. 

Sometimes  it  will  be  apparent  that  a  sinus  of  long  standing  does  not 
close  because  the  constant  and  long-continued  passage  of  irritating  and 


Fig.  94. — Irrigating  a  Sints. 

infectious  discharges  has  converted  it  into  a  stiff  and  thick-walled  tube 
of  scar  tissue,  which  will  not  collapse,  and  which  serves  as  a  very  poor 
base  for  the  growth  of  granulation  tissue.  In  such  a  case,  if  one  is  sure 
that  the  original  infection  has  lost  most  of  its  virulence,  it  may  be  wise 
to  employ  a  sinus  curet  and  scrape  the  walls  part  way  through,  down 
to  a  well-nourished  substratum.  If  this  does  no  good,  the  sinus  may 
be  packed  with  gauze  and  dissected  out  entire.  In  other  cases  where 
the  discharge  continues  profuse  over  a  considerable  period  of  time,  or 
if  for  any  other  reason  one  is  led  to  infer  that  the  degree  of  resistance 
exhibited  by  the  patient  toward  the  specific  organism  which  is  respon- 
sible for  the  condition  is  low,  the  recently  developed  science  of  vaccine 


SINUSES    AND    FISTUL^E 


243 


therapy  may  be  brought  in  to  assist  us.  The  organism  being  isolated 
and  identified,  a  stock  vaccine  may  be  bought  and  injected,  or  the  organ- 
ism may  be  cultivated  and  a  vaccine  developed  (see  Chapter  LII).  If 
the  infection  is  mixed,  involving  two  or  more  species  of  bacteria,  the 
treatment  becomes  more  complicated.  The  results  of  this  form  of  treat- 
ment are  sometimes  striking. 

The  cases  in  which  a  sinus  is  kept  open  by  the  persistence  of  the 
discharge  from  a  bit  of  necrotic  tissue,  a  suture,  or  other  foreign  body 
are  comparatively  common.  As  already  mentioned,  the  offending 
body  may  be  a  splinter  of  bone,  the  distal  portion  of  a  sloughed-off 
appendix,  a  silk  or  catgut  suture  or  ligature,  or  a  gauze  sponge.  Some- 
times a  stitch,  or  even  a  bit  of  necrotic  appendix,  may  be  washed  out 


Fig.  9S. — Inserting  a  Wick. 
The  gauze  is  held  taut  between  forceps  in  one  hand  and  fingers  of  the  other  hand,  and  is  thus  inserted  at  once 

to  the  bottom  of  the  wound. 


through  the  sinus  if  a  nozzle  is  used  which  reaches  to  the  bottom  of 
the  cavity,  and  the  irrigating  fluid  is  allowed  to  enter  under  pressure  of 
5  or  6  feet.  A  crochet  hook  is  a  useful  instrument  in  exploring  stitch 
sinuses,  and  with  one  it  is  often  possible  to  fish  out  a  ligature  which  has 
become  a  source  of  trouble.  Another  maneuver  is  to  bend  sharply 
upon  itself  a  strand  of  silkworm  gut,  and  introduce  the  loop  into  the 
sinus,  twisting  it  upon  itself,  in  the  hope  of  entangling  the  recalcitrant 
knot  of  silk  or  catgut.  As  a  final  resource,  the  sinus  may  be  cureied, 
then  gradually  dilated  with  uterine  dilators,  and  with  a  pair  of  urethral 
forceps  a  minute  search  instituted  over  its  entire  sides  and  bottom  in 
the  endeavor  to  loosen  and  grab  the  ligature. 

In  the  days  when  silk  was  the  only  material  used  in  the  abdomen 


244  SINUSES    AND    FISTULA 

and  pelvis  operators  had  much  trouble  from  such  stitch  sinuses.  The 
material  would  be  contaminated  by  the  surgeon's  hands  or  the  tissues 
which  it  was  made  to  tie,  give  rise  to  an  abscess,  which  was  about  as 
likely  to  discharge  into  the  bladder  or  rectum  as  through  the  abdominal 
wound,  Uterorectal  and  uterovesical  fistulce  were  by  no  means  rare, 
and  sometimes  the  patient  had  to  be  operated  upon  for  calculi  formed 
about  ligatures  which  had  worked  their  way  into  the  bladder.  Since 
we  have  gotten  into  the  habit  of  using  absorbable  material  for  our  buried 
sutures  and  intra-abdominal  ligatures,  and  have  learned  better  our 
aseptic  technique,  these  accidents  have  become  far  less  frequent,  al- 
though even  now  a  batch  of  poorly  sterilized  catgut  may  give  rise  to  a 
small  epidemic  of  stitch  abscesses. 

In  the  treatment  of  appendix  abscess  it  sometimes  occurs  that,  for 
various  reasons,  after  the  pus  is  let  out  no  more  than  a  hasty  search  can 
be  made  for  the  appendix  itself.  If  the  appendix  is  not  found,  a  reason- 
able length  of  time  is  allowed  for  it  to  find  its  way  out  in  the  discharges. 
If  this  does  not  happen,  and  the  sinus  does  not  close,  it  will  become 
necessary  to  perform  a  secondary  operation  for  the  purpose  of  finding 
and  removing  the  appendix.  In  cases  where  the  abdominal  sinus 
persists,  and  there  is  no  evidence  as  to  its  source,  it  is  well  to  bear  in 
mind  the  possibility  of  a  sponge  or  other  foreign  body  being  left  inside 
the  peritoneal  cavity,  or  the  existence  of  tuberculosis. 

A  sinus  which  is  discharging  at  all  freely  should  be  dressed  once  or 
twice  a  day.  It  should  be  gently  syringed  out  with  a  mild  antiseptic 
and  a  large  absorbent  dressing  applied.  Drainage  should  be  insured 
by  the  employment  of  a  gauze  wick  or  a  tube.  Ordinarily  a  fenestrated 
rubber  tube  of  the  proper  caliber,  with  fairly  stiff  walls,  is  to  be  pre- 
ferred; it  drains  adequately  and  continuously,  from  the  very  bottom 
of  the  cavity,  and  it  is  easily  and  painlessly  removed  and  inserted.  It 
can  be  progressively  shortened  as  the  cavity  fills  in  from  the  bottom 
with  granulations.  The  part  should  be  kept  at  rest  to  insure  healing, 
and  it  is  sometimes  of  advantage  to  apply  a  judicious  amount  of  pres- 
sure, by  means  of  adhesive  strapping  or  the  bandage,  to  aid  in  the 
coaptation  of  the  walls  of  the  cavity  and  to  facilitate  filling  in.  Dress- 
ings should  be  carried  on  under  aseptic  precautions,  as  mixed  infections 
are  ordinarily  more  difficult  to  treat. 

The  treatment  of  a  fistula  is  the  treatment  of  the  organ  from  which 
it  leads.  In  general,  a  fistula  will  continue  to  excrete  so  long  as  there 
remains  any  impediment  to  the  normal  excretion  from  the  gland  or 
viscus  from  which  it  takes  origin.  In  some  cases,  from  the  nature  of 
the  primary  condition,  there  can  be  no  hope  of  restoring  the  natural 


LYMPHATIC    FISTULA  245 

exit,  and  thus  a  patient  may  carry  about  a  renal  fistula  or  a  perineal 
fistula  for  the  rest  of  his  life.  Otherwise,  the  principle  of  treatment 
is  to  encourage  the  discharge  through  the  vice  naturales,  as  by  tying  a 
catheter  into  the  bladder,  and  so  give  the  fistula  rest  and  allow  it  to  heal. 
When  this  can  be  accomplished,  the  fistula  will  usually  be  found  to  heal 
rapidly,  but  sometimes  plastic  operations  are  necessary  for  their  final 
closure.  Fistulee  may  close  temporarily  and  then  reopen,  and  keep 
alternating  thus  between  open  and  closed  for  some  weeks  or  months 
before  they  decide  finally  to  remain  closed.  Sometimes,  on  account  of 
the  pain  from  the  pressure  of  the  pent-up  secretion  behind  a  temporarily 
closed  biliary  fistula,  it  will  be  necessary  to  reopen  the  mouth  of  the 
tract  with  a  knife. 

LYMPHATIC  FISTULA 

It  occasionally  happens  that  in  dissections  of  the  neck  the  thoracic 
duct  is  accidentally  opened,  severed,  or  tied  off.^  The  integrity  of  this 
lymph-channel,  conveying  the  final  products  of  absorption  from  the 
digestive  organs  into  the  blood-current,  must  be  considered  vital  to 
the  existence  of  the  organism,  and  any  injury  that  it  may  sustain  is  to 
be  looked  upon  as  serious. 

The  thoracic  duct,  which  drains  the  lymphatics  of  the  entire  body 
except  those  of  the  right  head,  neck,  and  arm,  comes  up  into  the  neck 
at  the  left  of  the  esophagus  and  behind  the  left  subclavian  artery.  At 
the  level  of  the  seventh  cervical  vertebra  it  arches  outward,  over  the 
subclavian  artery,  to  terminate  in  the  left  subclavian  vein  just  before 
it  joins  the  internal  jugular  to  form  the  innominate.  Its  course  is 
inconstant — in  nearly  one-half  of  the  cases  it  divides  into  two  or  more 
radicles;  in  half  of  these  it  joins  again,  in  the  other  half  it  opens 
by  two  or  more  orifices,  sometimes  joining  with  the  right  lymphatic 
duct.^ 

Symptoms. — If  the  thoracic  duct  is  severed,  edema  appears  about 
he  wound,  which  opens,  and  large  quantities  of  thick,  curdy  material 
are  poured  out.  The  digestive  organs  work  to  no  purpose,  and  the 
patient  suffers  from  excruciating  hunger  and  thirst.  The  discharge 
of  chyle  increases  as  the  amount  of  food  ingested  is  increased,  but  no 
matter  how  much  the  patient  eats,  the  emaciation  and  weakness  pro- 
gress.    If  pressure  is  exerted  in  an  attempt  to  limit  the  outpouring  of 

^  Lund  (Boston  Med.  and  Surg.  Jour.,  1899,  cxl,  354)  reports  a  case  of  operative 
injury  of  the  thoracic  duct  following  a  radical  operation  for  removal  of  the  breast  and 
referred  to  13  similar  cases.     The  patient  recovered. 

2  Parsons  and  Sargent,  On  the  Termination  of  the  Thoracic  Duct,  Lancet,  London, 
April  24,  1909. 


246  SINUSES   AND   FISTULA 

chyle  the  edema  increases,  the  patient  complains  of  pain  in  the  thorax, 
and  as  soon  as  the  pressure  is  relieved,  there  is  a  profuse  discharge  of 
pent-up  chyle.  The  heart's  action  weakens  as  the  condition  progresses, 
and  loss  of  consciousness  and  finally  death  ensue. 

Prognosis. — Death  is  by  no  means  the  necessary  outcome  of  this 
accident.  Many  cases  have  been  reported  which  have  recovered 
spontaneously  after  a  profuse  discharge,  lasting  some  days  or  even 
weeks.  When  we  consider  that  in  nearly  half  the  cases  there  exist 
multiple  ducts,  it  is  probable  that  in  these  reported  instances  the  surgical 
injury  involved  damage  to  one  division  only,  and  that  a  second  collateral 
channel  already  existed. 

Treatment. — If  the  injury  is  noted  at  the  time  of  operation,  the 
treatment  should  be  the  same  that  one  would  accord  in  case  of  a  similar 
injury  to  an  arterial  trunk;  if  the  wall  is  only  nicked,  it  should  be  sutured; 
if  the  duct  is  cut  across,  its  end  should  be  ligated  in  the  hope  that  col- 
lateral branches  exist;  if  it  cannot  be  reached,  a  clamp  should  be  applied 
or  compression  exerted  by  means  of  a  pressure  dressing.  The  implanta- 
tion of  the  cut  end  of  the  duct  into  a  vein  has  been  attempted. 

In  a  considerable  proportion  of  the  cases  the  injury  is  overlooked 
at  the  time  of  operation  and  the  first  sign  of  its  occurrence  is  the  presence 
of  pain  and  edema  about  the  wound.  The  edema  may  spread  up 
onto  the  left  side  of  the  face  and  down  the  left  arm.  In  the  presence  of 
this  edema,  sufficient  sutures  should  be  released  to  give  free  exit  to  the 
chylous  discharge.  A  large  absorbent  dressing  should  be  applied 
without  much  pressure.  Zinc  oxid  ointment  or  Friar's  balsam  should 
be  applied  to  save  the  skin  from  being  excoriated.  Everything  should 
be  done  to  maintain  the  patient's  nutrition  until  such  time  as  the  col- 
lateral branches  are  able  to  take  up  their  vocation.^ 

FECAL  FISTULA  AND  ARTIFICIAL  ANUS 

A  fecal  fistula  is  a  fistula  communicating  with  the  bowel  and  dis- 
charging fecal  matter.  When  such  a  fistula  is  created  purposely  by 
sewing  the  cecum,  colon,  or  small  intestine  to  the  abdominal  wall,  it  is 
called  an  artificial  anus. 

Fecal  fistula  is  usually  an  unavoidable  though  troublesome  complica- 
tion of  the  after-treatment  of  celiotomies;  it  sometimes  arises  from 
causes  which  might  have  been,  avoided.     Whether  or  not  the  surgeon  can 

^  For  further  consideration  rf  the  subject  see  Unterberger,Ueber  Operativen-Verletzungen 
des  Ductus  Thoracicus,  Beitr.  zur  klin  Chir.,  xl\di,  Heft  3;  v.  Graff,  Zur  Therapie  der 
Operativen-Verletzungen  des  Ductus  Thoracicus,  Wein.  klin.  Woch.,  1905,  Nr.  i;  De 
Forrest,  The  Surgery  of  the  Thoracic  Duct,  Ann.  Surg.,  1907,  -^Ivi,  705. 


FECAL    FISTULA    AND    ARTIFICIAL   ANUS  247 

be  rightly  held  accountable  for  the  formation  of  a  fecal  fistula  in  a  given 
case,  the  patient  himself  will  ordinarily  be  apt  to  feel  that  the  operator 
is  in  some  way  personally  responsible  for  the  unclean  and  disabling 
condition  from  which  he  suffers. 

The  most  frequent  cause  of  fecal  fistula  is  appendix  abscess,  either 
in 'the  form  in  which  the  appendix  has  sloughed  off  and  the  base  cannot 
be  found  and  ligated,  or  such  a  ligature  does  not  hold,  or  the  wall  of 
the  cecum  or  the  neighboring  ileum  has  been  rendered  necrotic  and 
friable  by  the  septic  process  and  breaks  open  at  the  time  of  the  operation 
or  later.  The  ligature  of  the  stump  has  been  known  to  "blow  off"  in 
clean  cases,  however,  and  give  rise  to  a  fecal  fistula.  Fistulas  may 
appear  after  operations  for  the  repair  of  traumatic  wounds  of  the  in- 
testines and  after  intestinal  anastomoses,  where  for  some  reason  the 
line  of  sutures  has  leaked.  They  may  result  from  slight  and  apparently 
insignificant  tears  of  the  bowel  in  separating  adhesions  and  during  the 
removal  of  tumors  to  which  one  or  more  loops  of  intestine  are  closely 
adherent,  even  if  only  the  outermost  layer  or  layers  of  the  intestinal  wall 
are  stripped  off. 

If,  in  the  reduction  of  a  strangulated  hernia,  the  replaced  gut,  con- 
trary to  the  surgeon's  expectations,  proves  nonviable,  a  fecal  fistula  may 
result.  It  may  result  also  from  the  presence  of  a  foreign  body,  a  stitch 
abscess,  or  from  the  perforation  of  a  tuberculous  or  other  intestinal 
ulcer.  It  may  follow  pressure  from  gauze  packing,  put  in  perhaps  for 
hemorrhage  at  the  time  of  operation,  left  for  too  long  a  time  pressing 
on  a  coil  of  gut,  or  from  continued  pressure  of  a  glass  or  stiff  rubber 
drainage-tube.  It  has  been  known  to  follow  accidental  puncture  of 
the  gut  by  the  needle  in  sewing  up  the  abdominal  wound.  In  any  case 
if  the  point  of  leakage  is  not  closed  off  from  the  general  abdominal 
cavity  by  adhesions,  or  an  easy  tract  of  exit  appears  through  the  abdom- 
inal wound,  the  case  is  likely  to  end  in  peritonitis. 

If  an  opening  in  the  gut  has  been  left  at  the  time  of  operation,  and 
a  drainage-tube  is  in  situ,  gas  and  pus  of  a  fecal  odor  may  appear  at  the 
first  dressing  and  fecal  matter  become  evident  within  twenty-four  hours. 
Sometimes  a  fistula  does  not  establish  itself  for  weeks  after  the  operation. 
The  color  and  nature  of  the  discharge  vary  with  location  of  the  per- 
foration—the higher  up  in  the  intestinal  tract,  the  more  fluid  and  the 
lighter  in  color.  The  discharge  from  any  fecal  fistula  is  irritating  to 
the  skin,  biit  the  discharges  which  come  from  the  higher  portions  of  the 
intestines  are  particularly  acrid,  and  those  from  the  duodenum  may  even 
digest  the  skin  down  to  the  fascia. 

Prophylactic  treatment  consists  in  avoiding  the  possibilities  which 


248  SINUSES   AND   FISTULA 

have  already  been  suggested — particular  care  should  be  exercised  in 
handling  tissues  which  may  be  friable  and  in  separating  adhesions; 
anastomoses  should  not  be  dropped  until  they  are  demonstrated  air- 
tight, and  all  rents,  even  if  they  go  only  partially  through  the  intestinal 
wall,  should  be  well  sewed  up;  and  drainage  of  any  sort  should  not  be 
allowed  to  exert  too  great  a  pressure  or  to  stay  in  place  for  too  long  a 
time. 

Once  a  fistula  has  established  itself  one  must  first  of  all  see  to  it  that 
there  is  no  obstruction  to  free  drainage — all  gauze  should  be  removed 
and  the  sinus  dilated  occasionally,  if  it  shows  signs  of  closing  down 
prematurely,  or  kept  open  by  a  rubber  tube.  The  chief  danger  is  from 
the  backing  up  of  feces  under  pressure.  The  fistulous  tract  should  be 
kept  as  clean  as  possible  by  irrigating  it  out  once  a  day  with  a  solution 
of  chlorinated  soda,  using  a  female  glass  catheter  as  a  tip  to  the  douche 
tube  in  order  to  reach  its  every  part.  The  skin  about  the  wound  should 
be  protected  by  washing  once  a  day  with  alcohol,  drying  and  paint- 
ing an  area  round  about  2  in.  in  diameter  with  compound  tincture  of 
benzoin. 

Healing  is  encouraged  by  attempts  to  divert  the  fecal  contents 
through  its  natural  channels.  The  diet  should  be  moderate,  easily 
digestible,  and  leaving  as  small  a  residue  as  possible.  To  prevent  any 
back  pressure-  in  the  intestinal  stream  the  movements  of  the  bowels 
should  be  stimulated  by  repeated  low  enemas,  but  not  by  cathartics. 
The  patient  should  maintain  a  position  in  bed  which  will  dispose  the 
intestinal  matter  to  pass  through  the  regularly  ordained  channel  rather 
than  through  the  fistula. 

Ordinarily,  under  this  regimen,  fistulae  from  appendix  stumps  and 
other  small  wounds  of  the  intestine  will  heal,  and  any  constant  diminu- 
tion in  the  discharge,  however  slight,  should  encourage  perseverance. 
If  the  discharge  continues  unabated  for  a  considerable  period,  operative 
treatment  should  be  considered,  bearing  in  mind  that  fistulas  sometimes 
close  spontaneously  after  existing  for  six  or  more  months. 

ARTIFICIAL  ANUS 

An  artificial  anus  is  made  deliberately  for  the  purpose  of  diverting 
the  intestinal  stream.  Sometimes,  as,  for  instance,  in  malignant  cases, 
it  is  intejided  to  serve  permanently — usually  the  formation  of  an  artificial 
anus  is  a  temporary  expedient. 

An  artificial  anus  should  be  dressed  frequently  and  particularly 
good  care  should  be  taken  of  the  skin.  Some  sort  of  belt  or  binder 
may  be  devised  to  hold  a  pad  of  gauze  against  the  wound  to  catch  the 


ARTIFICIAL  ANUS  249 

discharges.  As  soon  as  the  bowels  begin  to  resume  their  function,  the 
discharge  of  feces  through  the  artificial  anus  lessens,  and  a  man  may 
be  about  and  attend  to  his  affairs  if  he  carries  a  pad  or  two  of  gauze 
for  a  change  if  necessary.     (See  also  Colostomy,  p.  421,  for  details.) 

Artificial  anus  does  not  tend  to  heal  spontaneously.  As  soon  as  it 
has  served  its  purpose,  operation  will  be  necessary  for  closure.  The 
usual  operation  consists  in  dissecting  the  loop  free  from  its  adhesions 
to  the  abdominal  wound,  sewing  up  the  intestinal  opening,  and  dropping 
it  into  the  abdominal  cavity.  The  earlier  this  is  done  after  the  primary 
operation,  the  easier  it  will  be  to  separate  the  adhesions. 


CHAPTER  XXVI 

SEPTICOPYEMIA 

Septicemia  is  a  toxemia  arising  from  a  focus  of  septic  infection; 
pyemia  is  the  name  applied  to  the  condition  ^vhen  multiple  abscesses 
occur  in  various  parts  of  the  body  from  lodgment  and  multiplication 
of  bacteria  deposited  by  the  blood-current.  In  both  these  forms  of 
generalized  septic  infection  the  bacteria  exist  in  the  blood-stream  and 
may  be  demonstrated  by  planting  the  blood,  taken  under  aseptic  con- 
ditions, on  culture-media;  in  cases  of  septicemia,  however,  the  organ- 
isms are  less  numerous  in  the  peripheral  circulation  than  in  the  capil- 
laries of  the  internal  organs,  such  as  the  kidneys,  liver,  and  spleen, 
and  it  is,  therefore,  often  impossible  to  detect  them  antemortem.  As 
the  two  conditions  cannot  ordinarily  be  sharply  distinguished  clinically, 
and  as  they  have  a  common  etiology,  it  will  be  convenient  to  consider 
them  both  under  the  heading  septicopyemia. 

Any  acute  inflammatory  or  suppurative  condition  which  is  due  to  a 
microorganism  may  give  rise  to  a  secondary  or  a  systemic  infection. 
The  organisms  which  are  usually  met  with  are  the  Staphylococcus 
pyogenes  aureus  (common  In  circumscribed  acute  abscesses,  carbuncles, 
etc.),  the  Streptococcus  pyogenes  (occurring  in  spreading  superficial 
inflammations,  diffuse  phlegmons,  lymphangitis,  and  erysipelas),  the 
Bacillus  coli  communis  (associated  with  inflammatory  and  suppura- 
tive conditions  of  the  abdominal  contents),  and,  less  frequently,  the 
Micrococcus  tetragenus  (often  found  alone  or  associated  with  other 
organisms  in  suppurative  conditions  about  the  mouth  and  neck) .  Meta- 
static inflammations  and  suppurations  may  follow  certain  acute  diseases, 
such  as  gonorrhea,  pneumonia,  and  typhoid,  and  frequently  occur  in 
tuberculosis;  in  such  secondary  foci  the  corresponding  organisms  may 
at  times  be  isolated.  Secondary  infection  may  occur — (i)  through  the 
lymphatics,  (2)  along  natural  channels,  such  as  the  urethra,  ureters, 
and  bile-ducts,  and  (3)  by  way  of  the  blood-vessels:  organisms  may  be 
carried  along  directly  by  the  blood-current;  a  septic  phlebitis  may  cause 
the  formation  of  a  thrombus,  which  disintegrates  as  a  result  of  the 
suppuration  and  forms  septic  emboli,  or  there  may  be  a  direct  extension 
along  a  vein,  as  in  suppurative  pylephlebitis. 

250 


PROGNOSIS  251 

Virulent  bacteria  may  be  disseminated  by  means  of  infected  emboli, 
phlebitis,  or  lymphangitis.  In  this  case  we  speak  of  the  condition 
clinically  as  pyemia  or  septicometastasis.  Pyogenic  organisms  exercise 
a  peptonizing  and  hquefying  action  on  blood-clot.  As  a  result,  in- 
fected particles  may  be  taken  up  by  the  lymphatic  and  venous  circula- 
tion and  carried  to  the  various  parts  of  the  body.  In  the  lymphatic 
system  they  cause  lymphangitis  and  abscesses  of  the  glands  of  the  groin, 
axilla,  and  neck.  Thrombi  reaching  the  portal  system  cause  the  de- 
velopment of  mesenteric  and  hepatic  abscesses.  In  the  systemic  veins 
the  thrombi  are  carried  to  the  lungs.  If  they  pass  through  the  pul- 
monary circulation,  those  that  do  not  lodge  in  the  heart  enter  the  arterial 
current  and  may  be  distributed  over  the  body  to  the  brain,  liver,  kidneys, 
etc. 

Symptoms. — Locally,  skin  wounds  show  marked  signs  of  septic 
inflammation,  often  of  the  lymphangitis,  and  inflammation  of  the 
neighboring  lymph-nodes.  The  skin  and  subcutaneous  tissues  become 
brawny  and  infiltrated  and  erysipelas  may  set  in.  There  may  be  crepita- 
tion from  the  formation  of  gas  if  the  bacillus  of  malignant  edema  (Bacil- 
lus aerogenes  capsulatus)  is  present.  If  the  source  of  infection  is  an 
operative  wound,  pus  may  exude  from  the  stitch  holes  and  from  bet\veen 
the  edges  of  the  wound. 

The  objective  symptoms  in  septicemia  are  marked — rapid  rise  in 
temperature  to  101°  or  over,  the  process  being  initiated  by  a  chill;  the 
pulse  grows  gradually  more  rapid,  the  tongue  becomes  dry  and  glazed, 
and  the  skin  hot.  As  a  rule,  the  temperature-curve  is  irregular,  the 
fever  is  apt  to  be  low  in  the  morning  and  rise  a  degree  or  two  toward 
evening.  It  is  at  its  lowest  at  about  seven  or  eight  in  the  morning, 
when  it  may  be  even  subnormal.  The  pulse  in  severe  cases  reaches 
140  or  160  a  minute,  and  as  fatal  termination  approaches  it  becomes 
weak  and  thready.  The  respiratory  rate  runs  above  normal.  The 
patient  is  frequently  delirious  as  the  temperature  rises,  and  at  times 
may  be  even  maniacal,  although  he  is  more  apt  to  exhibit  the  condition 
of  drowsiness  or  stupor.  There  may  be  a  complicating  septic  meningitis. 
The  bowels  are  usually  constipated,  although  the  stools  may  be  watery; 
the  urine  is  apt,  as  a  rule,  to  show  albumin  and  casts;  it  is  scanty  in 
amount  and  high  colored. 

Diagnosis. — Diagnosis  may  be  made  absolute  by  the  isolation 
of  bacteria  from  the  blood. 

Prognosis. — Prognosis  of  septicemia  is  always  grave.  If  septic 
metastases  develop,  the  prognosis,  as  a  rule,  is  bad.  If  the  site  of  the 
original  infection  is  superficial,  where  it  may  be  thoroughly  cleaned 


252  SEPTICOPYEMIA 

and  drained,  the  result  will  be  more  propitious.  The  question  of  the 
virulence  of  the  infection  and  the  susceptibility  and  resistance  of  the 
patient  must  always  form  the  premises  upon  which  prognosis  is  based. 
Treatment. — Free  drainage  of  the  original  site  of  the  infection 
and  of  all  superficial  secondary  abscesses.  One  should  not  hesitate 
at  amputation  of  a  limb  if  such  a  mutilating  operation  is  necessary  in 
the  effort  to  save  life.  The  general  treatment  should  be  supportive 
and  stimulating,  the  diet  should  be  easily  digestible,  made  up  chiefly  of 
eggs,  milk,  broth,  cereals,  custards,  whisky,  and  the  patient  should 
be  fed  at  frequent  intervals.  Strychnin  and  whisky  are  the  best  stimu- 
lants. The  bowels  should  be  kept  acting  freely  by  the  use  of  calomel 
or  salts.  Antipyretics  are  contraindicated  on  account  of  their  depressing 
action.  Sponging  with  cold  water  and  alcohol  rubs,  with  the  ice-cap 
when  needed,  form  the  best  means  of  controlling  temperature.  In  the 
earlier  stages  normal  salt  solution  should  be  given  by  rectum.  In 
critical  cases  250  to  500  cc.  may  be  given  every  four  to  six  hours.  In 
desperate  cases  the  venous  infusion  of  500  to  1000  cc.  may  be  given. 
Metastatic  abscesses  should  be  incised,  evacuated,  and  drained  when 
accessible.  If  septicemia  becomes  chronic,  Fowler's  solution  or  elixir 
of  iron  and  gentian  should  be  exhibited.  The  use  of  bacterial  vaccines 
has  been  followed  by  good  results  in  some  cases.  (For  discussion  of 
this  subject  and  technique,  see  Chapter  LII. 


CHAPTER  XXVII 

CUTANEOUS  RASHES:  ETHER  RASH,  SEPTIC  RASH, 
ERYSIPELAS,  SURGICAL  SCARLATINA,  DRUG  POI- 
SONING 

Cutaneous  rashes  and  eruptions  are  likely  to  be  seen  occasionally 
following  operations,  especially  celiotomies.  Usually  the  operation  is 
only  indirectly  responsible  for  their  occurrence.  They  may  take  the 
form  of  an  urticaria;  the  eruption  may  be  papular,  it  may  be  macular 
and  resemble  measles,  or  erythematous,  like  scarlet  fever.  Often  it 
will  be  found  that  nothing  more  than  a  digestive  disturbance  is  respon- 
sible for  their  outbreak,  but  they  may  be  due  to  drugs  taken  internally, 
such  as  morphin,  or  used  externally,  such  as  iodoform,  or  to  irritant 
enemas,  as  of  turpentine.  Occasionally  they  are  the  outward  evidence 
of  so  serious  a  condition  as  septicemia,  and  it  must  not  be  forgotten 
that  measles  and  scarlet  fever  may  themselves  complicate  convalescence. 
While  it  is  true  that  these  postoperative  rashes  are  usually  only  of  passing 
importance,  they  are  likely  to  cause  considerable  anxiety  before  they 
are  identified,  and  they  should  never  be  allowed  to  go  without  a  diagnosis. 

ETHER  RASH 

During  etherization  there  not  infrequently  appears  on  the  face, 
neck,  and  chest  a  bright  roseolous  rash  which  marks  the  height  of  vascular 
excitement.  The  patches  are  large,  sharply  outlined,  irregularly  shaped, 
and  asymmetrically  placed.  They  appear  suddenly,  just  about  as  the 
patient  reaches  full  surgical  anesthesia,  maintain  their  vividness  for 
two  or  three  minutes,  and  then  slowly  fade.  It  is  most  common  in 
women,  and. usually  affects  the  area  supplied  by  the  superficial  cervical 
plexus.     It  is  undoubtedly  of  nervous  origin. 

No  treatment  is  necessary. 

SEPTIC  RASH 

Associated  with  symptoms  of  septicemia  there  sometimes  appears 
within  the  course  of  a  few  hours  a  generalized  or  limited  erythematous 
eruption  resembling  that  of  scarlet  fever.  Frequently,  particularly  in  chil- 
dren, it  occurs  without  any  other  evidence  of  general  septic  infection, 
although  its  appearance  is  sometimes  preceded  or  followed  by  a  breaking 

253 


254  CUTANEOUS  RASHES 

down  and  suppuration  of  the  wound.  Whether  this  is  cause  or  effect 
cannot  be  stated. 

The  eruption  occurs  ordinarily  three  or  four  days  after  the  opera- 
tion. It  is  ushered  in  by  restlessness  and  malaise,  and  with  its  appear- 
ance the  temperature  rises  to  about  102°  F,  and  the  pulse-rate  goes  up 
proportionately.  It  is  usually  uniform  in  its  distribution,  with  a  pre- 
dilection for  the  upper  half  of  the  body.  In  mild  cases,  unaccompanied 
by  septicemia,  it  usually  lasts  two  to  four  days  and  then  begins  to  fade 
out.  If  the  eruption  has  been  at  all  severe,  it  is  followed  by  desquama- 
tion. 

Just  how  closely  this  condition  is  allied  to  scarlet  fever  it  would  be 
difficult  to  say.  That  it  has  been,  and  may  be,  confused  with  scarlatina 
there  can  be  no  question.  It  differs  from  this  latter  condition  as  it 
ordinarily  presents  itself  in  that  it  appears  rapidly,  without  premonitory 
symptoms,  such  as  sore  throat  and  vomiting.  The  characteristic 
"strawberry"  tongue  of  scarlatina  is  absent.  The  rash  does  not  appear 
progressively  on  the  neck,  chest,  and  face  as  the  scarlatinal  rash  typically 
does.  The  fever  does  not  run  so  high,  and  in  some  cases  at  least  it  is 
intermittent.  It  is  not  complicated  by  otitis  media  or  cervical  adenitis. 
Finally,  it  is  often  allied  to  wound  suppuration  or  general  septicemia. 

Treatment. — Symptomatic  and  supportive;  catharsis  as  indi- 
cated, and  treatment  of  any  associated  septic  condition  which  may  be 
allied  causally.  Until  the  diagnosis  is  clear,  isolation  is  advisable.  A 
powder  of  zinc  oxid  and  starch  may  be  applied. 

ERYSIPELAS 

The  occurrence  of  erysipelas  after  clean  operations  which  have 
been  performed  with  due  respect  for  the  rules  of  aseptic  technique  is 
rare.  Erysipelas  may,  however,  show  itself  after  operations  for  the 
relief  of  septic  conditions  or  the  repair  of  wounds  accompanied  by  more 
or  less  extensive  destruction  of  tissues.  It  occurs  particularly  in  those 
whose  resistance  is  lowered  by  exposure,  alcohol,  debility,  or  old  age. 
The  infecting  organism  is  usually  the  Streptococcus  pyogenes,  although 
it  has  been  recently  stated  that  the  Staphylococcus  aureus  may  be  the 
organism  in  some  cases.  Pathologically,  the  condition  is  a  lymphangitis, 
the  organism  finding  its  way  by  some  surface  lesion  into  the  superficial 
lymphatic  system,  multiplying  rapidly  and  spreading  throughout  the 
lymph-spaces  from  the  point  of  inoculation  by  continuous  growth. 
The  organisms  may  be  best  demonstrated  in  the  advancing  margin  of 
inflammation. 

The  onset  is  usually  marked  by  a  chill  and  gastric  disturbance. 


SURGICAL    SCARLATINA  255 

The  temperature  rises  to  102°  F.  or  over  and  remains  at  about  this 
point.  The  patient  is  prostrated.  In  twelve  to  twenty-four  hours  he 
complains  of  a  burning  or  itching  about  the  wound,  and  examination 
reveals  a  contiguous  patch  of  infiltration,  elevated,  tender,  sharply 
outlined,  and  dusky  red  in  color.  There  is  usually  an  accompanying 
serous  discharge  from  the  wound.  The  inflammation  advances  irreg- 
ularly, preserving  its  raised  sinuous  border,  the  color  fading  out  in 
the  center.  This  progression  is  maintained  for  a  variable  length  of 
time — from  a  few  days  to  many  weeks — before  it  gradually  clears  up. 
It  usually  leaves  the  patient  exhausted  and  relapses  occur  in  about 
10  per  cent,  of  the  cases.  The  prognosis  should  always  be  guarded, 
on  account  of  the  possibilities  of  gangrene,  cellulitis,  and  metastatic 
infection  occurring  as  direct  complications,  or  secondary  pneumonia 
or  nephritis.  The  mortaHty  may  be  roughly  stated  at  10  per  cent.; 
it  is  much  higher  in  infants  and  in  the  old  or  debilitated. 

Treatment. — The  patient  should  be  kept  quiet  and  apart  from 
other  patients.  He  should  be  well  nourished  with  a  sufficient,  though 
light,  diet,  and  brandy  or  strychnin  should  be  employed  if  stimulation 
is  called  for.  Morphin  will  often  be  necessary.  The  bowels  should 
be  kept  moving  freely  with  calomel  or  salines.  Locally,  all  wounds 
should  be  kept  surgically  clean.  The  inflammatory  area  should  be 
kept  moistened  with  a  refrigerant  lotion,  such  as  equal  parts  of  camphor 
water  and  ether,  applied  every  half-hour  with  a  camel's-hair  brush. 
If  the  infection  is  about  the  face,  the  eyes  should  be  protected  by  com- 
presses of  iced  boric-acid  solution.  If  for  any  reason  the  application 
of  the  lotion  cannot  be  kept  up  through  the  night  regularly,  a  10  per 
cent,  ichthyol  ointment  may  be  applied  at  eight  o'clock  and  wiped  off 
the  next  morning.  In  case  of  abscess  formation  free  incision  and 
drainage  should  be  performed,  without  general  anesthetic  if  possible. 

SURGICAL  SCARLATINA 

At  this'  date  there  can  be  hardly  any  question  but  that  scarlet  fever 
may  follow  surface  lesions,  surgical  or  traumatic.  Many  cases  have 
been  reported  following  operation,  but  some  have  run  an  atypical  course, 
and  probably  many  of  these  are  of  the  type  which  we  have  already  con- 
sidered under  Septic  Rash.  It  must  also  be  borne  in  mind  that  a  child 
may  be  operated  upon  unknowingly  during  the  incubation  stage.  Some 
of  the  true  cases  of  scarlet  fever  developing  comparatively  late  in  con- 
valescence are  undoubtedly  due  to  contagion  from  the  doctor,  a  nurse, 
or  a  neighboring  patient. 

In  a  few  cases  that  have  been  closely  observed  it  is  highly  prob- 


256  CUTANEOUS   RASHES 

able  that  a  surface  lesion  was  the  site  of  primary  inoculation  on 
account  of  the  presence  of  an  areola  and  lymphangitis  about  the  wound, 
the  shortness  of  the  period  of  incubation,  the  typical  course  with  com- 
plications, and  contagion  from  the  patient  resulting  in  the  occurrence  of 
the  disease  in  others, 

Postoperative  scarlatina  is  most  frequent  in  children.  It  follows 
surface  lesions,  such  as  burns  or  lacerated  wounds,  and  operations  of 
one  sort  or  another,  but  it  has  been  most  commonly  reported  after 
operations  about  the  nose  and  throat,  as  for  removal  of  tonsils  and  ad- 
enoids.    The  treatment  does  not  differ  from  that  generally  employed.* 

DRUG  POISONING 

Skin  eruptions  may  follow  the  use  of  antiseptics  or  other  local  ap- 
plications, the  internal  use  of  drugs,  or  the  use  of  enemas. 

The  commoner  drugs  which  are  likely  to  cause  eruptions  are  atropin 
and  belladonna,  the  bromids,  chloral,  the  coal-tar  derivatives,  such 
as  antipyrin  and  acetphenetidin,  the  iodids,  mercury,  morphin  and 
opium,  salicylic  acid  and  the  salicylates,  sodium  benzoate,  chlorate 
of  potash,  and  strychnin.  I  have  in  mind  a  case  of  a  man  who  is  poisoned 
by  the  slightest  dose  of  mercury  in  any  form,  such  as  calomel  internally 
or  the  bichlorid  externally,  the  administration  being  followed  always 
by  a  severe,  almost  universal,  eczema.  While  the  appearance  of  the 
efflorescence  caused  by  each  one  of  these  drugs  has  certain  peculiarities 
by  which  they  may  be  sometimes  differentiated,  they  all  have  points  in 
common  which  distinguish  them  from  other  eruptions  in  general  and 
aid  in  diagnosis. 

As  a  rule,  a  medicinal  rash  resulting  from  drugs  taken  internally 
may  be  recognized — (i)  By  its  rapidity  of  development;  (2)  its  symmetry; 
(3)  the  absence  of  fever;  (4)  its  existence  alike  on  exposed  and  protected 
surfaces  of  the  skin;  (5)  its  tendency  to  generalization;  (6)  pruritus, 
and  (7)  the  fact  of  medication  with  a  drug  known  to  cause  skin  erup- 
tions. Any  generalized  rash  which  makes  its  appearance  suddenly, 
if  we  can  exclude  syphilis  and  the  acute  exanthems,  is  likely  to  be  a  drug 
eruption.  They  disappear  rapidly,  as  a  rule,  upon  the  discontinuance 
of  the  responsible  drug. 

*  Kredel  (Wundscharlach,  Arch.  f.  klin.  Chir.,  1908,  Ixxxvii,  No.  4)  states  that  in  the 
Hanover  Hospital  28  cases  of  scarlet  fever  developed  among  the  patients.  In  12  the  in- 
fection followed  an  extensive  operation  and  in  i  a  severe  burn.  The  incubation  was  only 
three  days  in  10  and  from  five  to  eight  days  in  the  others.  He  is  convinced  that  the  infection 
occurred  in  the  operating  room,  and  believes  that  antiseptic  rather  than  aseptic  measures 
might  be  preferable  during  prevalence  of  scarlet  fever.  Van  der  Bogart  (Arch,  of  Pediat- 
rics, Feb.,  1909)  cites  a  case  of  scarlet  fever  following  a  wound  in  the  foot. 


DRUG   POISONING  257 

Cases  of  local  poisoning  from  the  use  of  antiseptics  are  uncommon, 
but  by  no  means  rare.  Most  of  the  ordinary  agents  \\\\\  excite  a  local 
reaction  if  applied  too  strongly  or  too  freely,  especially  if  their  action 
is  concentrated  by  applying  a  moisture-proof  covering,  such  as  oiled  silk 
or  waxed  paper,  over  the  dressing. 

The  question  of  personal  idiosyncrasy  seems  to  be  an  important 
factor  in  the  occurrence  of  drug  eruptions  of  all  sorts;  apart  from  this, 
poisoning  is  more  liable  to  develop  in  children  than  in  adults  and 
in  persons  who  have  unsound  kidneys.  Ordinarily  an  erythematous 
rash  appears  under  and  about  the  edges  of  the  dressing,  bright  red  in 
color,  and  may  itch  badly.  Sometimes  the  eruption  may  spread  for 
some  distance  about  the  wound.  Unless  the  condition  has  progressed 
so  far  as  gangrene, — as  it  will  after  the  use  of  strong  carbolic  acid, — this 
local  reaction  will  usually  promptly  disappear  if  the  irritant  is  much 
diluted  or  changed  altogether  for  something  more  mild,  and  the  skin 
protected  from  its  action  by  boric  or  zinc  oxid  ointment. 

There  are  only  a  few  of  the  antiseptics  in  common  use  which  by  their 
local  application  may  cause  systemic  poisoning  through  absorption.  Of 
these,  the  most  important  are  iodoform,  carbolic  acid,  and  its  derivative, 
picric  acid. 

Iodoform  poisoning'  may  follow  the  use  of  iodoform  powder 
in  large  quantity  on  raw  surfaces,  the  use  of  iodoform  gauze  in  pack- 
ing cavities,  and  the  use  of  iodoform  emulsion  or  paste  in  tuber- 
culous glands  and  sinuses  and  osteomyelitis.  As  a  rule,  there  is  an 
areola  of  inflammation  resembling  erysipelas  surrounding  the  wound, 
and  there  may  be  the  formation  of  serous  vesicles.  The  first  sign  that 
things  are  going  wrong  is  drowsiness.  The  temperature  rises  suddenly 
to  102°  F.  or  over;  there  are  accompanying  nausea  and  vomiting.  Within 
twenty-four  to  forty-eight  hours  a  generalized  eruption  appears,  scarla- 
tiniform  in  type.  The  pulse-rate  rises,  and  signs  of  collapse  are  ap- 
parent; the  patient  is  delirious,  becomes  comatose,  and  may  die;  the 
urine  becomes  black  and  shows  the  presence  of  iodin. 

Treatment. — All  iodoform  should  be  removed  as  rapidly  and  as 
thoroughly  as  possible.  Any  free  iodin  left  behind  may  be  taken  up 
by  scrubbing  the  surface  with  moistened  starch  or  irrigating  with  a 
solution  of  starch  in  warm  water.  The  patient  should  be  supported 
and  stimulated,  the  bowels  and  kidneys  flushed  by  the  use  of  salines, 
diuretics,  and  water  by  m.outh,  under  the  skin,  and  by  rectum. 

Carbolic  acid  or  phenol  has  a  considerable  and  lengthening 
list  of  fatalities  to  its  credit,  although  cases  of  death  from  its  use  externally 
are  at  present  rare.     If  enough  carbolic  acid  in  solution  is  applied 

17 


258  CUTANEOUS   RASHES 

over  a  rav;  surface  to  allow  absorption  in  sufficient  amount,  the  patient 
within  a  few  hours  becomes  pallid  and  drowsy,  the  respiration  is  labored 
and  stertorous,  and  coma  gradually  develops,  followed  by  collapse;  the 
urine  is  dark  green  or  black  and  lacks  sulphates. 

The  treatment  of  this  form  of  poisoning  consists,  first,  in  removing 
the  source  of  the  absorption,  and,  second,  in  the  administration  of 
Glauber's  or  Epsom  salt  and  general  supportive  measures. 

Poisoning  from  picric  acid  is  occasionally  reported  following  its 
imprudent  use  in  the  treatment  of  burns.  Although  a  number  of  cases 
of  poisoning  have  been  reported  after  topical  applications,  and  suicidal 
attempts  have  been  made  by  taking  it  internally,  it  is  not  certain  that 
picric  acid  has  ever  been  the  direct  cause  of  death.  Poisoning  is  readily 
recognized  by  the  intense  yellow  color  which  the  deposit  of  this  pigment 
gives  to  the  skin  and  mucous  membrane.  The  urine  may  be  yellow, 
brown,  or  black.  There  are  some  nausea  and  vomiting  and  headache. 
It  is  differentiated  from  jaundice  by  the  presence  of  bile  in  the  stools. 
As  soon  as  the  use  of  the  drug  is  discontinued,  the  symptoms  disappear 
and  the  yellow  color  of  the  surface  of  the  body  begins  to  fade. 

Occasionally  the  use  of  enemas  will  be  followed  by  a  skin  eruption. 
It  may  be  local  and  patchy,  like  measles,  or  generalized,  like  scarlet 
fever.  It  shows  up  shortly  after  the  administration  of  a  rectal  injection, 
in  anywhere  from  four  to  eighteen  hours,  and  it  usually  lasts  two  to 
four  days.  There  is  no  fever.  As  to  its  causation,  there  is  some  question. 
It  will  follow  the  injection  of  turpentine  and  the  use  of  common  yellow 
soap  in  making  suds  enemas.  No  treatment  is  necessary  beyond  the 
use  of  an  antipruritic  lotion,  such  as  white  wash  (carbolic  acid,  i  dr., 
zinc  oxid,  i  oz.,  lime-water,  to  make  i  pt.). 

References 

Prince  A.  Morrow,  Drug  Eruptions,  New  York,  1887. 

Roswell  Park,  Iodoform  Poisoning,  Boston  Med.  and  Surg.  Jour.,  1893,  cxx\'ii,  138. 
T.  S.  Stone,  Iodoform  and  Carbolic  Poisoning,  Amer.  Jour.  Obstet.,  1902,  xlv,  93. 
Gottheil,  Diagnosis  of  Commoner  Drug  Eruptions,  Arch,  of  Diagnosis,  April,  190S. 
F.  J.  Shepherd,  Eruptions  Occurring  After  Abdominal  Operations,  Jour.  Cut.  Dis., 
1909,  xxvii,  293. 


CHAPTER  XXVIII 

RARE  COMPLICATIONS:  TETANUS,  MALIGNANT  EDEMA, 
PAROTITIS,  STATUS  LYMPHATICUS,  HEMOPHILIA 

POSTOPERATIVE  TETANUS 

In  the  early  days  of  abdominal  surgery  it  was  not  rare  for  patients, 
a  few  days  after  the  operation,  to  develop  symptoms  of  tetanus,  and 
these  cases  frequently  proved  fatal.  Twenty  years  ago  and  more  the 
matter  was  of  sufl&cient  importance  to  give  rise  to  a  considerable  litera- 
ture. Olshausen  ^  first  described  it  as  occurring  after  ovariotomy,  and 
he  collected  49  cases;  Edmund  Rose^  in  1897  collected  58  cases; 
v.  Cackovic,^  60  cases;  Zacharius  *  adds  18  cases,  and  W.  G.  Richard- 
son ^  adds  21  more,  making  a  total  of  206  cases.  Of  these,  the  large 
majority  have  been  fatal. 

The  sources  to  which  the  infection  has  usually  been  ascribed  are 
the  use  of  infected  catgut  ^  and  kangaroo  tendon,^  the  use  of  gelatin 
which  has  become  contaminated  by  tetanus  bacilli,®  or  contagion  from 
another  patient  in  the  hospital  through  a  nurse.^ 

It  cannot  be  questioned  but  that  in  the  majority  of  reported  instances 
the  infection  is  referable  to  catgut.^" 

It  was,  however,  first  observed  in  the  cases  of  Zacharius  that  the 
catgut  might  be  sterile  on  bacteriologic  examination.  Richardson  ex- 
amined the  catgut  in  14  of  his  21  cases  and  found  it  negative  in  every 
instance,  although  in  4  cases  a  bacillus  resembhng  that  of  tetanus  was 

^  Krankheiten  der  Ovarien,  Deut.  Chir.,  Lief  58,  1886. 
^  Der  Starrkrampf  beim  Menschen,  Deut.  Chir.,  Lief  8,  1897. 
^  Central,  der  Chir.,  1897,  xxiv,  728. 

*  Miinch.  med.  Woch.,  1908,  i,  227. 

^  Tetanus  Occurring  After  Surgical  Operations,  Brit.  Med.  Jour.,  1909,  vol.  i,  948. 
^  Gunn,  Post -operative  Tetanus,  Dublin  Jour,  of  Med.  Sci.,  1909,  cxxviii,  i. 
'  Dorsett,  Amer.  Jour.  Obst.,  1902,  xlvi,  620. 

*  Haddaeus,  Tetanus  nach  subcutaner  "Gelatine-Injection,  Miinch.  med.  Woch.,  1909, 
231. 

^  Aspell,  Amer.. Jour.  Obst.,  1900,  xlii,  867. 

'°  R.  Kleinertz,  Tetanus  from  Catgut,  Berlin.  kHn.  Woch.,  1909,  xlvi,  1654;  and 
Reuben  Peterson,  Tetanus  Developing  Twelve  Days  After  Shortening  of  the  Round 
Ligaments,  Jour.  Amer.  Med.  Assoc,  1910,  liv,  108. 

259 


26o  RARE   COMPLICATIONS 

found.  It  was  suggested  to  him  that  in  the  locahty  in  which  these 
cases  occurred  sheep  ordinarily  harbored  tetanus  bacilh  in  their  in- 
testinal tract  in  large  numbers.  From  this  suggestion  he  deduced  the 
theory  that  the  tetanus  bacilli  were  not  introduced  with  the  catgut, 
but  that  the  patient  at  the  time  of  operation  was  a  host  of  the  bacillus 
and  the  cases  were  all  to  be  considered  as  cases  of  idiopathic  tetanus, 
in  which  the  disturbance  of  opening  the  peritoneum  was  enough  to 
cause  the  bacillus  to  become  toxic. 

This  theory  of  the  causation  of  postoperative  tetanus  has  recently 
aroused  some  interest  in  this  country.  Matas,  at  the  meeting  of 
the  American  Surgical  Association  held  in  June,  1909,  read  a  paper 
on  the  Fecal  Origin  of  Some  Forms  of  Postoperative  Tetanus  and  its 
Prophylaxis  by  Proper  Dietetic  and  Culinary  Measures.^  He  reported 
2  cases  which  occurred  after  the  patient  had  eaten  copiously  of  un- 
cooked vegetables. 

The  result  of  his  careful  consideration  of  this  subject  may  be  summed 
up  as  follows:  Postoperative  deaths  from  tetanus  sometimes  occur  in 
apparently  clean  cases.  The  risk  of  tetanus  infection  can  be  practically 
eliminated  in  all  operations  upon  sterile  tissues  in  which  a  rigorous 
postoperative  asepsis  can  be  maintained  until  healing  has  occurred. 
In  those  regions  in  which  postoperative  asepsis  cannot  be  secured, 
for  example,  the  extremities  and  the  anorectal  region,  the  liability  to 
occurrence  of  tetanus  cannot  be  completely  removed.  Occasionally 
postoperative  deaths  are  not  necessarily  dependent  upon  defects  of 
technique  or  contaminated  materials,  such  as  imperfectly  sterilized 
catgut:  they  may  be  due  to  the  direct  contamination  of  the  alimentary 
canal  and  its  contents  with  living  tetanus  bacilli  and  their  spores 
swallowed  in  uncooked  vegetables,  berries,  and  other  fruits  which 
are  cultivated  in  fertile  or  manured  soil;  that  is  to  say,  soil  that  con- 
tains the  tetanus  bacilli.  He  calls  attention  to  the  fact  that  in  both 
his  cases  the  patients  had  previously  partaken  of  uncooked  vegetables. 
All  cultivated  soil  in  the  temperate  and  tropic  zones  contains  tetanus 
bacilli.  They  grow  more  luxuriantly  in  the  soil  of  the  tropics  than  in 
the  temperate  zone,  and,  therefore,  to  a  certain  extent,  tetanus  is  a 
disease  of  warm  climates. 

Tetanus  bacilli  and  their  spores  survive  the  passage  through  the 

intestinal  canal  of  domesticated  animals,  particularly  the  horse  and 

the  cow,  and  the  dejecta  of  these  animals  are  perfect  culture-media  for 

the  bacilli.    Of  normal  adult  men,  5  per  cent,  harbor  the  tetanus  bacillus 

»  or  its  spores  in  an  active  state  in  the  intestinal  canal,  and  20  per  cent. 

^  Monthly  CyclopEedia  and  Medical  Bull.,  1909,  ii,  705. 


POSTOPERATIVE    TETANUS  261 

of  hostlers,  dairymen,  and  others  intimately  associated  with  domestic 
animals  show  tetanus  bacilh  in  their  feces. 

Matas  concludes  that  whenever  a  patient  is  to  be  operated  on  in 
any  region  where  fecal  contamination  is  unavoidable,  such  as  in  cases 
of  hemorrhoids,  fistula,  stricture,  etc.,  antitetanic  preparation  should 
be  insisted  upon.  This  consists,  first,  of  purgation  for  three  days 
before  operation,  and,  second,  suppression  of  all  uncooked  food, 
especially  green  vegetables,  berries,  and  fruit,  for  the  same  period. 
These  rules  apply  particularly  to  the  warm  portions  of  the  country 
and  sections  where  the  tetanus  bacilli  are  known  to  abound.  In  cases 
of  emergency,  when  dietetic  preparation  is  impossible,  lo  cc.  of  tetanus 
antitoxin  may  be  injected  subcutaneously  at  the  time  of  operation. 

Gelatin  has  long  been  known  to  harbor  tetanus  bacilli  over  long 
periods,  and  ordinarily  sterilization  has  been  found  impotent  to  destroy 
their  virulency.  If  gelatin  is  to  be  used  for  subcutaneous  injection,  the 
bacilli  and  their  spores  must  be  destroyed  beyond  a  question  of  doubt. 
A  practical  and  competent  method  for  accomplishing  this  purpose  is 
described  by  Wandel.^  The  gelatin  in  a  neutralized  lo  per  cent,  solu- 
tion is  sterilized  in  an  Erlenmeyer  jar,  covered  with  a  layer  of  fluid 
paraffin  to  keep  out  oxygen.  A  long  glass  tube  reaches  to  the  floor 
of  the  jar,  the  upper  end  being  capped  with  a  tube  and  stop-cock.  A 
larger  short  tube  in  the  stopper  filled  with  cotton  allows  the  entrance 
of  air.  The  whole  is  sterilized  in  a  linen  bag  in  steam  for  forty  minutes 
at  100°  C.  After  cooling,  it  is  kept  in  the  incubator  at  31°  C,  then 
sterilized  again  for  thirty  minutes  as  at  first,  and  this  is  repeated  for 
fifteen  minutes  the  following  day.  The  gelatin  thus  sterilized  is  poured 
into  sterile  vials  containing  50  cc,  and  these  are  then  fused.  Gelatin 
thus  sterilized  and  preserved  can  be  kept  indefinitely. 

The  treatment  of  postoperative  tetanus  is  that  of  trau- 
matic tetanus  after  the  development  of  symptoms.  If  the  source  of 
toxin  supply  can  be  reached,  it  must  be  disinfected,  if  possible,  by  the 
use  of  antiseptics.  Hutchins^  states  on  experimental  evidence  that 
amputation  of  an  infected  limb  is  of  little  curative  value,  because  at 
the  time  of  the  appearance  of  symptoms  the  body  probably  contains 
the  maximum  of  toxin.  Use  of  antitetanic  serum  in  this  stage  of  the 
disease  to  neutralize  the  toxin  alrea,dy  circulating  in  the  system  is  rarely 
to  be  depended  upon,  but  in  spite  of  this  it  may  be  useful  to  inject  10 
or  20  cc.  subcutaneously  in  the  neighborhood  of  the  wound,  10  to  20 
cc.  intravenously,  and  if  the  patient's  life  is  in  imminent   danger,    20 

^  Gelatin  in  Therapeutics,  Thcrapic  dcr  Gegonwart,  1909,  1,  265. 
•  ^  Festschrift  liir  Rindflcisch,  1907. 


262  RARE    COMPLICATIONS 

to  30  min.  into  the  spinal  cord.^  Exhaustion  should  be  combatted  by 
proper  feeding,  which  may  have  to  be  carried  on  through  a  tube,  and 
by  careful  stimulation.  The  patient  should  be  kept  quiet  in  a  dark 
room.  Free  diuresis  and  diaphoresis  should  be  instituted.  Water 
should  be  taken  copiously.  To  lessen  the  high  degree  of  nervous  irri- 
tability and  the  constant  muscular  contractions,  some  sedative,  such  as 
chloral  or  the  bromids,  should    be  exhibited. 

There  has  been  considerable  success,  so  far  as  diminishing  the 
reflex  symptoms  goes,  following  the  intraspinal  injection  of  magnesium 
sulphate,  as  suggested  by  Meltzer.  This  inhibits  the  convulsive  seizures 
and  produces  ascending  paralysis,  beginning  in  the  lower  extremities 
when  injected  into  the  lumbar  spine.  Care  should  be  exercised  in  compu- 
ting the  dose  or  it  may  be  followed  by  death.  The  dose  for  a  male  adult 
should  be  i  cc.  of  the  25  per  cent,  solution  for  every  20  pounds  weight. 

Dr.  Willard  H.  Hutchins,  after  experience  in  6  cases,^  recommends 
the  use  of  chloretone  for  the  control  of  the  muscular  manifestations. 
He  asserts  that  the  drug  is  harmless,  easy  of  administration,  and 
prompt  in  action.  From  30  to  75  gr.  may  be  given,  dissolved  in  i  ounce 
of  whisky,  if  the  patient  can  swallow,  or  through  a  stomach-tube,  or  in 
I  ounce  of  hot  olive  oil  by  rectum.  The  dose  can  be  repeated  every 
twenty-four  or  forty-eight  hours,  as  indications  arise.  He  suggests  as 
probable  that  the  therapeutic  effect  of  the  antitoxin  is  due  to  the  car- 
bolic acid  or  tricresol  which  it  contains  as  a  preservative,  and  which 
in  itself  is  strongly  recommended  by  Baccelli.^ 

GAS-BACILLUS  INFECTION 

The  Bacillus  aerogenes  capsulatus  is  closely  allied  morphologically 
to  the  tetanus  bacillus.  It  is  anaerobic  and  its  habitat  is  soil  and  street 
dirt.  Like  the  tetanus  bacillus,  it  is  found  in  the  intestinal  tract  of  man 
and   animals.     Infections  with   the  gas  bacillus  are  likely   to  follow 

^  Rogers,  Jour.  Amer.  Med.  Assoc.,  1905,  xlv,  12.  On  the  theory  that  the  toxin  is 
centripetal  and  finds  its  way  to  the  central  nervous  system,  it  has  been  suggested  that 
there  would  be  an  advantage  in  cutting  down  upon  the  nerve-trunks  supplying  the  part 
infected  and  injecting  antitoxin  into  these  directly.  Success  has  been  reported  with  this 
technique.  Nathan  Jacobson  (Trans.  Amer.  Surg.  Assoc,  1906),  after  an  exhaustive 
stud}',  was  led  to  conclude  that  there  was  practically  no  difference  to  be  noted  in  the 
result,  no  matter  how  the  antitoxin  was  administered.  The  recent  isolation  of  tetanus 
bacilli  from  enlarged  glands  by  C.  A.  Porter  and  Oscar  Richardson  (Two  Cases  of 
"Rusty  Nail ' '  Tetanus  with  Tetanus  Bacilli  in  the  Inguinal  Glands,  Boston  Med.  and 
Surg.  Jour.,  1909,  clxi,  927)  may  give  an  entirely  different  aspect  to  our  treatment  of  the 
disease,  bringing  it  into  the  classification  with  the  septicemias. 

^  Trans.  Amer.  Surg.  Assoc,  1909,  xxvii,  279. 

^  SuU'azione  delle  iniezione  di  acido  fenico  nelle  neoralgie,  nel  tetano  e  nella  tisi, 
Lavori  di  Congressi  di  medicina  interna,  Roma,  1888,  i,  342. 


PAROTITIS  263 

extensive  lacerations  and  compound  fractures,  and  seem  to  be  most 
apt  to  occur  when  the  wound  has  been  contaminated  with  grease  and 
dirt  from  machinery  and  sliafting  or  wagon-wheels  and  car-trucks.  It 
has  been  known  to  follow  operation  about  the  rectum,  and  there  has 
recently  been  a  fatal  case  following  amputation  for  diabetic  gangrene 
at  the  Boston  City  Hospital. 

The  first  sign  of  gas-bacillus  infection  is  a  livid  or  bluish  appearance 
about  the  wound,  followed  rapidly  by  the  occurrence  of  gaseous  in- 
filtration, which  crackles  and  pits  on  pressure.  A  foul  reddish  secretion 
may  be  expressed,  which  contains  bubbles.  The  process  extends  rapidly 
in  the  form  of  a  moist  gangrene,  and  may  involve  the  entire  limb  within 
twenty-four  hours.  Profound  prostration  ensues,  and  the  patient  is 
likely  to  die  of  toxemia.  This  clinical  picture  accounts  for  the  name 
malignant  edema,  which  is  sometimes  given  the  condition. 

The  treatment  must  necessarily  be  heroic.  Free  incision  should 
be  made  wherever  there  is  infiltration,  and  moist  antiseptic  dressings 
should  be  continually  applied  or  the  continuous  bath  or  irrigation  em- 
ployed. On  the  theory  that  the  bacillus  cannot  live  in  the  presence  of 
oxygen,  hydrogen  dioxid  may  be  used  freely,  or  a  stream  of  oxygen 
may  be  carried  direct  into  the  tissues.^  If  the  infection  has  involved 
a  limb,  amputation  offers  the  best  hope  for  recovery,  and  should  be 
performed  before  the  patient  becomes  too  depressed  to  stand  anesthesia.^ 

PAROTITIS 

Inflammation  of  the  parotid  glands  occurs  not  infrequently  after 
operations,  usually,  however,  after  operative  procedures  on  the  ab- 
dominal and  pelvic  viscera.  It  is  on  record  also  as  following  simple 
concussion  of  the  abdominal  organs.^  It  also  occurs  during  rectal 
feeding.*  It  is  found  to  occur  more  frequently  in  women  than  in  men.^ 
It  may  follow  any  injury  or  disease,  but  it  is  more  frequent  after  injuries 
and  operations  on  the  pelvic  organs  than  after  diseases  in  any  other 
part  of  the  body. 

In  onset  and  appearance  it  resembles  mumps.     The  swelling  may 

^  Thiriar,  Presse  Med.,  Beige,  1904,  Ivi,  555. 

^  Abner  Post,  Pseudo-malignant  Edema,  Boston  City  Hosp.  Med.  and  Surg.  Reports, 
1896,  seventh  series;  Paul  Thorndike,  Clinical  Report  of  Cases  of  Infection  due  to  the 
Bacillus  Aerogenes  Capsulatus,  Boston  Med.  and  Surg.  Jour.,  1900,  cxlii,  592;  Joseph  H. 
Pratt  and  Frank  T.  Fulton,  Report  of  Cases  in,  which  the  Bacillus  Aerogenes  Capsulatus 
was  Found,  Boston  Med.  and  Surg.  Jour.,  1900,  cxlii,  599. 

^  Kulka,  Secondary  Parotitis,  Wien.  klin.  Woch.,  1908,  xxi,  691. 

*W.  S.  Fenw^ck,  The  Prevention  of  Parotitis  during  Rectal  Feeding,  Brit.  Med. 
Jour.,  1909,  i,  1297. 

^  Paget,  Lancet,  1887,  i,  314. 


264  RARE   COMPLICATIONS 

be  one  sided  or  double,  and  other  salivary  glands,  such  as  the  sub- 
maxillary and  sublingual,  may  also  become  swollen.  The  inflamma- 
tion usually  appears  anywhere  from  five  to  ten  days  after  the  operation. 
Its  onset  is  accompanied  by  a  rise  in  temperature  which  lasts  for  two 
or  three  days,  together  with  pain  in  the  affected  gland.  Usually  the 
symptoms  are  not  severe.  The  swelling  may  disappear  by  resolution 
or  the  gland  may  become  septic.  The  temperature,  as  a  rule,  does  not 
rise  above  101°  or  102°  F,,  except  in  septic  cases. 

Suppuration  occurs  in  about  one-half  the  cases  following  operation. 
An  abscess  will  form  in  the  substance  of  the  gland,  and  unless  treated, 
this  is  likely  to  burst  into  the  mouth  or  burrow  a  path  into  the  external 
auditory  canal  or  down  the  neck  in  the  pharynx.^ 

The  origin  of  the  parotitis  following  trauma  or  operation  is  still 
somewhat  doubtful.  The  association  of  parotitis  with  operations 
upon  pelvic  organs  is  suggestive  of  the  oft-noted  occurrence  of  epididymi- 
tis and  ovaritis  following  epidemic  parotitis,  which  speaks  for  some 
association  bet^veen  this  gland  and  the  generative  organs.  Some  authori- 
ties consider  that  toxic  agents  circulating  in  the  blood  are  an  important 
factor  in  suppurative  parotitis.^  There  is  more  evidence,  however,  sup- 
porting the  theory  that  the  germs  enter  the  gland  by  way  of  the  mouth.^ 

A  patient  who  is  kept  upon  his  back  and  allowed  only  a  liquid  diet 
does  not  use  his  jaws  in  chewing,  and,  therefore,  is  not  apt  to  empty 
his  parotid  ducts  as  he  would  normally.  The  secretion  of  saliva  is 
diminished,  and  the  germs  present  in  the  mouth  take  on  an  added  viru- 
lence. They  make  their  way  through  the  duct  into  the  stagnant  gland, 
and  inflammation  ensues.  Parotitis  may  also  be  due  to  the  presence 
of  a  decayed  tooth  or  follow  the  pressure  of  the  fingers  of  the  anesthetist 
during  an  operation  in  holding  forward  the  jaw. 

The  treatment  of  this  condition  consists  in  keeping  the  teeth  and 
mouth  clean  and  the  bowels  active,  and  the  use  of  morphin  for  pain 
when  it  becomes  necessary.  Hot  fomentations  often  give  relief.  Chew- 
ing gum  or  sucking  a  rubber  nipple  will  oftentimes,  by  maintaining  the 
salivary  secretion,  aid  in  keeping  the  buccal  ca^•ity  clean,  and  thus  act 
as  a  prophylactic. 

Suppuration  should  always  be  suspected  if  pain  is  severe  and  pro- 
longed or  if  the  temperature  is  maintained  at  102°  F.  or  over.  \'\'hen 
suppuration  occurs,  incision  should  be  made  at  once,  with  care  that  the 
branches  of  the  facial  nerve  are  not  wounded.*     Even  if  no  pus  is  found, 

^  Bumm,  Miinch.  med.  Woch.,  1887,  xxxiv,  173.  "  Dyball,  Ann.  Surg.,  xl,  886. 

^  Soubeyran  and  Rives,  Arch.  Gen.  de  Chir.,  1908,  ii,  448. 

*  Daniel  Fiske  Jones,  Boston  Med.  and  Surg.  Jour.,  1902,  c.xl%-ii,  565. 


STATUS    LYMPHATICUS  265 

the  incision  will  usually  afford  relief.     After  incision,  Bier's  suction 
apparatus  may  be  employed  with  advantage. 

So  long  as  the  temperature  remains  normal  there  need  be  no  uneasi- 
ness. Ordinarily,  symptoms  are  slight  and  of  short  duration,  and  the 
only  disadvantages  are  the  depressing  effect  upon  the  patient's  mental 
condition  and  his  appetite,  and  the  pain  which  he  may  suffer.  Death 
has  occurred  from  secondary  cellulitis  of  the  neck  and  edema  of  the 

glottis. 

STATUS  LYMPHATICUS 

It  has  long  been  known  that  children  are  more  subject  to  sudden 
death  during  or  immediately  following  an  operation  than  adults.  Sudden 
death  has  occurred  in  children  who  are  apparently  in  normal  physical 
condition,  even  following  operations  of  short  duration,  such  as  tonsillec- 
tomy. The  fatality  has  seemed  to  be  independent  of  the  anesthetic 
used,  and  has  sometimes  occurred  when  no  anesthetic  at  all  was  em- 
ployed. According  to  some  authorities,  this  condition  is  the  most 
common  cause  of  sudden  death  during  chloroform  anesthesia  in  cases 
where  the  anesthetic  is  being  administered  by  an  expert. 

Autopsy  in  some  of  these  cases  of  sudden  death  has  demonstrated 
the  presence  of  an  enlargement  of  the  lymphatic  tissues  throughout  the 
body.  There  are  hyperplasia  of  the  lymphatic  system  in  general,  en- 
largement of  the  superficial  and  deep  lymph-nodes,  especially  those  in 
the  neck  and  the  axillae,  and  enlargement  of  the  spleen.  This  in  some 
cases  is  accompanied  by  a  persistent  or  enlarged  thymus.  The  associa- 
tion of  persistence  or  hypertrophy  of  the  thymus  with  sudden  death 
from  respiratory  interference  has  been  recognized  for  about  three  hundred 
years,  and  many  surgeons  of  to-day  are  coming  to  be  of  the  opinion  that  the 
thymus  is  the  essential  factor  in  what  is  usually  called  status  lymphaticus. 

The  existence  of  status  lymphaticus  during  life  can  never  be  more 
than  suspected.  The  fact  that  the  child  has  enlarged  adenoids  and 
tonsils  is  not  especially  significant.  If  this  enlargement  is  associated 
with  other  evidences  of  lymphatism,  such  as  general  glandular  enlarge- 
ment or  enlarged  spleen,  one  should  hesitate  before  administering  an 
anesthetic.  The  condition  is  known  also  to  be  associated  with  rickets, 
and  in  any  suspicious  case  one  should  look  for  enlargement  of  the  area 
of  thymic  dulness.  Children  who  are  subject  to  the  disorder  are  apt 
to  be  anemic,  with  the  pasty  complexion  and  anxious  facies  suggestive 
of  cretinism,- and  they  are  likely  to  be  subject  to  attacks  of  syncope 
and  dyspnea,  of  laryngismus  stridulus,  or  thymic  asthma.  They  may 
present  none  of  these  associated  conditions;  death  after  simple  opera- 
tion may  come  without  warning. 


266  RARE    COMPLICATIONS 

Usually  death  follows  so  suddenly  upon  the  first  appearance  of 
symptoms  that  treatment  is  of  no  avail.  Artificial  respiration  should 
always  be  instituted.  If  opportunity  allows,  measures  should  be  taken 
to  support  and  stimulate  the  patient.  Adrenalin,  camphor,  brandy, 
and  atropin  may  all  be  employed  with  the  hope  that  they  sustain  the 
patient.  If  there  seems  to  be  mechanical  pressure  upon  the  trachea  to 
such  a  degree  as  to  interfere  with  respiration,  tracheotomy  should  be 
performed.  The  introduction  of  large  quantities  of  fluid  by  all  possible 
avenues  may  dilute  an  overdose  of  thymic  secretion,  ^vhich  may  be  the 
condition  here  present. 

References 

R.  Park,  The    Status    Lymphaticus    and    the   Ductless   Glands,   Surg.   Gyn.   and 
Obst.,  1905,  i,  140. 

R.  E.  Humphn',  Clinical  and  Post-mortem  Observations  on  the  Status  Lymph- 
aticus, Lancet,  1908,  ii,  1870. 

W.  J.  McCardie,  Status  Lymphaticus  in  Relation  to  General  Anesthesia,  Brit. 
Med.  Jour.,  1908,  i,  196. 

W.  H.  Roberts,  The  Status  Lymphaticus  with  Particular  Reference  to  Anesthesia 
in  Tonsil  and  Adenoid  Operations,  Jour.  Am.  Lar.,  Rhin.,  and  Otol.  See,  1908,  507. 

HEMOPHILIA 

The  occurrence  of  postoperative  hemorrhage  has  already  been  con- 
sidered under  Chapter  VI.  Sometimes  a  patient  who  is  subject  to 
hemophiha  is  operated  upon  without  knowledge  of  h^s  condition,  and 
it  is  not  until  after  the  surgeon  notices  persistent  hemorrhage  following 
operation  that  he  is  led  to  make  inquiry  and  so'  arrive  at  a  diagnosis. 
Operations  of  any  degree  of  severity  on  hemophiliacs  are  frequently 
followed  by  fatal  results.  Surgical  measures,  therefore,  should  not  be 
knowingly  attempted  except  when  vital  necessity  exists.^  Before  opera- 
tion treatment  should  be  instituted  to  forestall  all  expected  hemorrhage. 
Serum  or  the  calcium  salts  should  be  administered. 

Treatment. — The  treatment  of  hemophilia  is  frequently  tedious 
and  oftentimes  barren  of  results.  It  should  be  followed  up  most  as- 
siduously, and  it  sometimes  resolves  itself  into  a  duel  bet^;^•een  death 
and  the  doctor.  Internally,  the  patient  should  be  stimulated  by  a  suf- 
ficient diet,  and  iron,  ergot,  or  thyroid  extract  may  be  administe'^ed. 
If  the  wound  is  accessible,  it  should  be  cleaned  thoroughly  down  to  ...e 
bleeding  surface,  and  a  styptic,  such  as  Monsell's  solution,  tannic  acid, 
or  adrenalin  in  the  form  of  powder  or  in  solution,  5  per  cent,  gelatin, 
or  4  per  cent,  cocain  solution;  on  pledgets  of  gauze,  should  be  applied 
direct  to  the  bleeding  capillaries.  These  applications  should  be  re- 
newed whenever  the  oozing  of  blood  is  sufficient  to  warrant  it.     If  firm 

^  Dahlgren,  Hygeia,  1908,  Ixx,  481. 


HEMOPHILIA  267 

pressure  can  be  brought  to  bear  upon  the  artery  which  suppHes  the 
part,  this  may  often  be  efficacious  in  bringing  the  hemorrhage  to  a  stop. 
For  nasal  hemorrhage  the  spraying  of  undiluted  hydrogen  dioxid 
into  the  nose  has  been  extolled.  For  hemorrhage  after  extraction  of 
teeth  freezing  the  surface  with  the  ethyl  chlorid  spray  has  been  recom- 
mended. 

Constitutional  Treatment. — Calcium  chlorid  has  in  some  cases  been 
followed  with  success  by  increasing  the  coagulation  of  the  blood;  again 
it  has  been  of  little  or  no  value.  .  The  same  may  be  said  of  gelatin  by 
mouth  or  subcutaneously.  Too  much  calcium  chlorid  will  increase  the 
coagulation  time  rather  than  diminish  it,  and  it  cannot  be  given  over 
too  long  a  period,  at  least  without  intermissions,  without  incurring  the 
same  result.  In  some  cases  it  has  been  useless.  The  use  of  calcium 
lactate  instead  of  calcium  chlorid  has  recently  been  followed  by  good 
results,  and  with  it  more  uniformity  and  certainty  of  action  can  be  ex- 
pected. There  has  been  reported  success  following  the  use  of  thyroid 
extract.^ 

The  Use  of  Animal  Serum.— It  has  long  been  known  that 
the  serum  which  separates  from  clotted  blood  contains  an  agent  which 
promotes  coagulation.  Hayem,  in  1882,  working  on  transfusion, 
demonstrated  that  injected  serum  possessed  the  power  of  increasing 
coagulability.  Weil,  while  studying  hemophilia,^  first  made  practical 
application  of  this  principle.  His  work  forms  the  basis  of  our  knowl- 
edge of  the  subject. 

Weil  injected  fresh  animal  sera  intravenously  or  subcutaneously 
for  the  purpose  of  preventing  or  controlling  hemorrhage.  He  found, 
by  clinical  observation  in  11  cases,  that  the  blood-serum  of  horses, 
rabbits,  and  cattle,  as  well  as  of  human  beings,  had  the  power  of  con- 
trolling hemorrhagic  processes  by  increasing  the  coagulability  of  the 
blood.  He  gave  up  the  use  of  beef-serum  on  account  of  the  toxic  symp- 
toms which  accompanied  it.  The  serum  should  be  fresh,  that  is,  less 
than  two  weeks  old,  and  15  cc.  should  be  given  intravenously  or  30  cc. 
subcutaneously  in  adults — half  as  much  in  children.  It  might  be  re- 
peated after  a  day  or  two  without  danger,  and  in  hereditary  hemophilia 
he  found  that  repeated  injections  were  usually  necessary.  The  use  of 
the  serum  locally  favored  clot-formation.  He  found  that  the  serum 
was  efficacious  in  relieving  all  hemorrhagic  conditions,  and  that  definite 
cures  usually  resulted  in  cases  of  sporadic  hemophilia  and  acute  purpura. 

*  Rugh,  Ann.  Surg.,  1907,  xlv,  666. 

2  L'Hemophille,  Pathogenic  et  Serotherapie,  Presse  Med.,  Oct.  18,  1905;  Des  Injec- 
tions, de  serum  sanguin  frais  dans  etats  hemorrhagipares,  Tribune  Med.,  Jan.  12,  1907. 


268  RARE    COMPLICATIONS 

Weil's  observations  were  confirmed  by  his  countrymen,  Elifagaray* 
and  Carriere.^  Broca,  in  Germany,  tried  the  method  ^  in  3  cases  of 
hemophiha,  using  diphtheria  antitoxin  locally  with  success.  He  de- 
cided that  the  method  was  very  valuable  as  a  temporary  expedient,  and 
suggested  that  the  injections  be  made  before  operation  as  a  prophylactic 
in  cases  where  a  disposition  to  bleeding  was  suspected.  He  suggested 
also  that,  although  the  method  could  not  be  considered  as  a  cure  for 
hereditary  hemophilia,  by  repeating  the  injections  every  three  months, 
using  sera  from  different  animals  so  that  the  danger  from  anaphylaxis 
would  be  lessened,  a  hemophiliac  could  be  practically  insured  against 
serious  hemorrhage. 

Lommel  *  reported  success  with  the  method  in  a  boy  of  four  years 
afflicted  with  hemophilia.  He  used  antistreptococcus  serum  which 
was  a  year  old,  being  the  only  serum  that  he  had  at  hand,  locally  and  in 
a  dose  of  20  cc.  subcutaneously.  He  was  obliged  to  give  10  cc.  more. 
Baum  ^  used  fresh  serum  after  the  Weil  method  in  3  cases  of  hemophilia 
with  moderate  success.  Gangani  ^  reported  partial  success  in  a  boy 
of  four  with  hemophilia  by  the  use  of  diphtheria  antitoxin.  Complete 
success  followed  the  use  of  fresh  rabbit  serum.  The  injection  of  10 
or  20  cc.  he  declared  should  be  repeated  and  pushed  beyond  the  maxi- 
mum generally  accepted.     The  fresher  the  serum,  the  better. 

Leary  ''  used  •  the  procedure  with  success  in  cases  of  hemophilia,  post- 
operative hemorrhage,  hemorrhage  of  the  new-born,  uterine  hemor- 
rhage, typhoid  hemorrhage,  purpura,  and  as  a  prophylactic  against 
hemorrhage  in  cases  of  jaundice  before  operation.  He  considers  the 
subcutaneous  method  as  more  desirable  than  the  intravenous  on  account 
of  the  danger  of  hemolysis  or  thrombosis  following  its  injection  into 
veins. 

Leary  uses  rabbit  serum  altogether.  It  can  be  obtained  aseptically 
by  cardiac  puncture  without  seriously  inconveniencing  the  animal. 
The  chest  is  shaved  over  the  sternum  and  left  side.  With  an  ordinary 
antitoxin  needle  a  puncture  is  made  to  the  left  of  the  sternum  and  about 
I  cm.  above  a  line  drawn  transversely  at  the  junction  of  the  sternum 

^  These  de  Paris,  1907. 

^  Miinch.  med.  Woch.,  1907. 

^  Med.  Klin.,  1907,  1445. 

*  Ueber  Blutstillung  mittels  Serum  bei  Haimophilie,  Zeit.  fiir  innere  Med.,  190S,  xxix, 
677. 

^  Der  Wert  der  Serumbehandlung  bei  Hamophilie  auf  Grund  experimenteller  und 
klinischer  Untersuchungen,  Mitt,  aus  den  Grenz.  der  Med.  und  Chir.,  1909,  xxi. 

^  Serum  as  Hemostatic  in  Hemophiliacs,  Gaz.  Deg.  Osp.,  1909,  xxx,  753. 

'  The  Use  of  Fresh  Animal  Sera  in  Hemorrhagic  Conditions,  Comm.  of  the  Mass. 
Med.  Soc,  1908,  xxi,  123. 


HEMOPHILIA  269 

and  ensiform.  A  needle. is  thrust  toward  the  middle  line  and  slightly 
upward.  The  puncture  usually  penetrates  the  left  ventricle.  Blood 
to  the  amount  of  30  cc.  is  slowly  withdrawn.  It  is  collected  in  sterile 
centrifuge  tubes.  After  a  short  stay  in  the  thermostat  the  clot  is  separated 
by  a  platinum  needle  and  the  material  shaken  in  an  electric  centrifuge 
and  the  serum  drawn  off. 

If  diphtheria  antitoxin  is  used  for  this  purpose,  it  should  be  less  than 
two  weeks  old.  The  serum  supplied  in  Massachusetts  by  the  State 
laboratory  is  from  six  weeks  to  six  months  old  before  it  is  delivered, 
because  it  has  to  be  kept  while  the  animals  are  being  watched  for  the 
development  of  tetanus  and  other  diseases.  The  same  objection  prob- 
ably holds  in  the  use  of  commercially  prepared  sera. 


CHAPTER  XXIX 

HABITS  AND  THEIR  RELATION  TO  SURGICAL  CONDI- 
TIONS: ALCOHOL,  MORPHIN,  COCAIN,  TEA,  TO- 
BACCO,   SNUFF 

AlcohoL — Surgically  speaking,  there  is  no  habit  of  worse  prog- 
nostic significance  than  the  alcoholic;  any  intemperate  person  is  a  poor 
surgical  risk.  Confirmed  alcoholics  present  serious  chronic  metabolic 
changes — cardiac  and  peripheral  arteriosclerosis,  enlarged  livers,  and 
impaired  kidneys — and  unstable  nervous  systems. 

There  are  two  great  classes  of  alcoholics:  the  constant  daily  tippler, 
with  his  occasional  week-end  spree,  and  the  periodic  victim  of  over- 
indulgence, who  between  times  is  an  almost  total  abstainer.  Of  the 
two,  the  latter  is  by  far  the  lesser  risk.  Other  things  being  equal,  his 
alcohol  does  not  so  seriously  lower  his  surgical  resistance.  Unfortunately 
for  him,  he  frequently  meets  the  surgeon  in  the  midst  of  one  of  his  sprees, 
the  unconscious  victim  of  an  accident.  As  a  rule,  his  acute  alcoholism 
does  not  seriously  affect  the  prognosis  of  the  case.  It  is  an  excellent 
plan  to  wash  his  stomach  out,  leaving  in  a  generous  dose  of  Epsom  salt 
and  bromids  if  he  is  at  all  unruly.  Ordinarily,  it  is  perfectly  safe  to 
give  him  ether  and  repair  whatever  slight  damage  there  may  be.  In 
severe  accidents,  aggravated  by  shock  or  hemorrhage,  the  prognosis 
in  his  case  is  made  much  more  serious  by  reason  of  his  habit. 

The  other  class  is  perhaps  more  often  met  with  surgically,  particu- 
larly in  hospital  practice.  The  surgical  trouble  is  often  trivial;  it  is 
the  alcoholic  habit  that  makes  the  case  serious.  Often,  either  because 
the  patient  wilfully  and  to  his  own  undoing  conceals  his  alcoholic  history, 
or  from  oversight  on  the  part  of  the  attending  physician,  or  from  the 
surgeon's  failure  to  appreciate  fully  the  serious  after-effects  of  chronic 
alcoholism,  the  patient  is  suddenly  wholly  deprived  of  his  customary 
stimulant.  His  nervous  system  at  once  wavers.  An  unnaturally  keen 
attentiveness  to  surroundings,  an  abnormally  active  response  to  trivial 
sensations,  and  a  slight  tremor  of  the  protruded  tongue  and  extended 
fingers  are  the  forerunners  of  the  terrible  visionary  hallucinations  and 
violent  delirium  by  which  the  nervous  system  reacts  to  its  deprivation. 
Delirium  tremens  is  the  price  that  alcohol  demands.  To  the  sudden 
deprivation  of  alcohol  are  added  ether  anesthesia  and  enforced  rest  in 

270  ■  , 


MORPHIN  271 

bed,  either  of  which  in  itself  is  sufficient  often  to  precipitate  an  attack 
of  delirium  tremens. 

Cheever^  effectively  sums  up  the  situation  in  the  following  paragraph: 

"Patients  who  do  not  drink  do  a  great  deal  better  than  those  who 
do  in  every  form  of  accident  and  injury.  The  calmness  of  the  body 
and  mind  is  with  the  temperate.  The  resistance  to  shock  is  with  the 
temperate.  The  ability  to  respond  to  stimulants  promptly  is  with 
the  temperate,  for  the  intemperate  have  already  used  up  their  powers 
of  vital  resistance;  they  have  become  accustomed  to  the  overuse  of 
stimulants,  and  they  do  not  respond  readily  to  them,  and  you  do  not 
get  the  benefit  from  stimulants  which  you  expect.  An  illustration  of 
this  is  seen  in  etherization;  as  we  said  before,  it  takes  a  great  quantity 
of  ether  and  laborious  and  excitable  and  protracted  etherization  to 
overcome  the  drunkard  and  make  him  go  to  sleep,  whereas  the  patient 
who  is  temperate,  as  a  rule,  takes  it  calmly,  succumbs  to  it  easily,  and 
recovers  promptly.  There  can  be  no  doubt,  I  think,  that  the  con- 
tinuous use  of  alcohol  has  a  deleterious  effect  on  the  tissues:  hardens 
them,  thickens  them,  prevents  absorption  as  readily,  dilates  the  veins, 
leads  to  a  slow  and  labored  circulation;  in  that  way  delays  absorption 
and,  moreover,  produces  finally  some  changes  in  the  brain  which  in  the 
end  are  structural.  All  these  things  count  against  the  patient  when 
he  is  suddenly  brought  to  meet  the  strain  of  a  severe  accident  or  a  severe 
operation." 

The  treatment  of  delirium  tremens  will  be  considered  later.  (See 
p.  273.)  To  prevent  its  development  it  is  always  permissible  to  give 
alcohol.  In  many  cases  beer  and  ale,  if  given  from  the  very  start,  will 
tide  a  whisky  drinker  over  the  critical  period.  The  patient  should 
be  got  out  of  bed  into  a  chair  as  soon  as  possible.  The  exercise  of 
pushing  a  Wheel-chair  about  serves  to  occupy  the  attention  and  will 
often  ward  off  an  incipient  case.  Etherization  should  be  postponed 
whenever  possible  until  the  nervous  system  has  become  steadied. 

Mo'rphin.2 — The  morphin  habitue  ordinarily  presents  a  fair  sur- 
gical risk,  provided  the  physical  condition  is  good.  It  is  essential,  as 
in  the  case  of  alcohol,  that  the  drug  be  continued  through  convalescence 
and  the  dose  gradually  reduced.  Few  cases  are  more  pitiable  than 
the  suddenly  restricted  morphin  fiend.  Moreover,  the  diarrhea,  rest- 
lessness, intense  misery,  and  persistent  apprehension  and  wakefulness 

*  Boston  Med.  and  Surg.  Jour.,  1893,  cxx^dii,  253. 

^  Much  may  perhaps  be  expected  from  the  Town  Treatment  of  these  drug  habits, 
recently  indorsed  by  Dr.  Alexander  Lambert,  of  New  York,  Jour.  Amer.  Med.  Assoc, 
1909,. liii,  985. 


272         HABITS   AND   THEIR   RELATION   TO   SURGICAL   CONDITIONS 

which  follow  the  sudden  withdrawal  of  morphin  constitute  a  more  than 
imaginary  danger.     Morphinism  must  be  recognized  as  a  disease. 

Cocain. — What  has  been  said  of  morphin  applies  equally  well  to 
cocain.  Before  the  patient  has  deteriorated  to  a  marked  degree  physi- 
cally from  the  use  of  the  drug  the  habit  should  not  be  a  contraindication 
to  necessary  operation.  Cocain  users  are  likely  to  suffer  from  sleep- 
lessness, tremors,  and  hallucinations,  together  with  digestive  disturbances 
and  emaciation.  If  they  are  deprived  of  the  drug,  there  is  apt  to  follow 
a  profound  physical  depression.  As  with  morphin,  if  the  opportunity 
is  allowed,  two  weeks  may  be  given  before  operation  to  the  gradual 
withdrawal  of  the  drug. 

Sudden  deprivation  of  tea  or  coflfee  in  those  who  are  accustomed  to 
use  them  to  excess  is  sometimes  followed  by  the  occurrence  of  a  tremor 
accompanied  by  nervous  excitation  and  wakefulness  without  delirium. 
This  has  been  noted  to  occur  also  in  inveterate  users  of  tobacco,  either 
smokers,  chewers,  or  inhalers  of  snuff.  Both  tea  and  tobacco  are  likely 
to  induce  functional  cardiac  disturbances,  such  as  palpitation  and 
pseudo-angina  pectoris,  which  may  compel  a  more  careful  etherization, 
and,  moreover,  they  may  even  bring  about  organic  degeneration  in  the 
heart  and  vessels,  which  may  have  serious  significance.  Ordinarily, 
however,  the  moderate  use  of  tea  and  tobacco  need  cause  no  anxiety. 
Deprivation  will  be  followed  ordinarily  by  nothing  worse  than  a  tem- 
porary nervousness  and  an  intense  longing  to  resume  the  habit.  In  so 
far  as  it  is  unwise  to  attempt  to  correct  habits  of  this  nature  during 
convalescence,  and  as  the  return  to  normal  is  hastened  by  agencies 
which  promote  comfort  and  sense  of  well-being,  it  will  often  be  found 
advisable  to  gratify  to  a  limited  extent  the  longings  of  patients  in  these 
matters.  One  cup  of  tea  or  one  pipe  of  tobacco  a  day  may  justify 
itself  by  reconciling  the  convalescing  patient,  in  part  at  least,  to  his 
enforced  confinement. 


CHAPTER  XXX 

POSTOPERATIVE   PSYCHOSES:    DELIRIUM    TREMENS, 
INSANITY,  MENOPAUSE 

DELIRIUM  TREMENS 

The  condition  of  maniacal  delirium  from  alcohol  poisoning  is  so  apt 
to  complicate  disastrously  surgical  convalescence  that  it  forms  an  im- 
portant subject  for  consideration.  We  meet  the  condition  in  one  of 
tv^^o  forms:  in  the  first  it  is  the  result  of  overindulgence — an  acute  alcohol 
poisoning;  the  other  form,  which  we  see  more  frequently,  results  from 
deprivation;  it  occurs  in  those  habituated  to  the  use  of  liquor,  even 
though  several  days  or  weeks  have  elapsed  since  they  have  partaken  of 
alcohol. 

Delirium  tremens  may  be  excited  by  nervous  shock  from  a  com- 
paratively slight  injury.^  It  may  follow  elective  operations  in  those 
who  are  accustomed  to  alcohol;  it  occurs  most  commonly  in  surgical 
practice  after  operations  of  necessity,  such  as  compound  fractures,  etc. 

In  cases  which  are  operated  upon  while  still  under  the  influence  of 
alcohol  a  delirium  accompanied  by  tremor  and  insomnia  may  occur 
directly  after  the  patient  has  recovered  from  the  anesthetic.  In  the 
more  common  form  a  period  of  hours  or  a  day  or  two  is  likely  to  elapse 
before  the  symptoms  become  so  evident  as  to  be  recognized.  The 
patient  at  first  is  quiet  and  subdued,  and  his  condition  toa  certain  degree 
resembles  that  of  mild  shock.  Then  there  gradually  develops  a  delirium 
in  which  the  chief  factor  is  usually  fear.  The  patient  suffers  from 
delusions  and  hallucinations,  which  he  sometimes  succeeds  in  conceal- 
ing from  the  physician  and  attendants,  and  he  makes  efforts  to.  escape 
from  the  danger  which  he  imagines  pursues  him.  Unless  he  is  care- 
fully watched,  these  attempts  may  result  in  injury  to  himself  or  others 
or  he  may  even  escape  from  the  ward  in  ^^•hich  he  lies. 

The  course  of  the  disease  may  be  divided  into  three  stages:  The 
first,  or  prodromal  stage,  is  characterized  by  the  condition  of  ner\'Ous 
apprehension.  This  usually  lasts  about  twelve  hours.  The  patient, 
as  a  rule,  is  submissive  and  extremely  anxious  to  comply  with  all  the 

^  Forge  and  Jcanbrau,  Death  from  Post-traumatic  Delirium  Tremens,  Pressc  Med., 
1909,  xvii,  19. 

.     18  273 


274 


POSTOPERATIVE   PSYCHOSES 


directions  which  are  given  him.  Whatever  he  is  asked  to  do  he  does- 
with  precipitance  and  sometimes  violence.  He  frequently  labors  under 
the  apprehension  that  he  is  going  to  die.  His  mind  is  changeable,  and 
no  impression  lasts  longer  than  a  few  seconds.  In  his  fear  of  death 
or  danger  he  forgets  pain,  and  he  may  get  out  of  bed,  tear  off  his  dress- 
ings, or  walk  about  on  a  fractured  leg  in  spite  of  the  admonitions  which 
have  been  given  him.  His  hands  and  tongue  are  markedly  tremulous. 
This  stage  shows  itself  usually  on  the  second  day  after  operation. 

The  second  stage  is  that  of  active  delirium.  The  state  of  apprehen- 
sion occasionally  gives  way  to  lapses  of  intelligence,  during  which 
illusions  of  sight  and  hearing  and  hallucinations  of  persecution  become 
evident.  The  patient  becomes  anxious  and  refuses  to  take  food.  He 
is  listless  and  may  lie  restlessly  quiet  for  hours  at  a  time,  muttering  un- 
intelligibly to  himself,  and  picking  at  the  bed-clothes  and  at  imaginary 
objects  in  the  air.  He  sees  insects  and  reptiles  or  other  animals  in  the 
corners  and  on  the  ceiling.  He  keeps  up  active  purposeless  movements 
without  intermission  until  he  perspires  from  weakness  and  sleep  is  an 
impossibility. 

From  this  stage  of  active  delirium  the  patient  is  likely  to  descend 
into  a  condition  of  low  muttering  delirium,  and  finally  stupor  develops. 
The  prostration  becomes  excessive,  pulse  soft  and  weak,  and  he  gradually 
sinks  into  a  coma  from  which  he  cannot  be  aroused  and  death  ensues. 

Treatment. — If  the  patient  has  been  operated  upon  while  still 
under  the  influence  of  an  alcoholic  debauch,  means  should  at  once  be 
taken  after  he  recovers  from  the  anesthetic  to  eliminate  whatever  of  the 
alcohol  may  still  remain.  A  stomach-tube  should  be  passed  and  the 
stomach  washed  out,  and  two  ounces  of  a  saturated  solution  of  Epsom 
salt  poured  into  the  stomach  through  the  tube.  He  should  be  given 
water  in  considerable  quantity  to  drink  and  potassium  acetate  in  doses 
of  15  gr.  to  further  aid  elimination  through  the  kidneys.  At  the  same 
time  he  should  be  sweated  by  means  of  a  hot-air  bath  or  hot  pack.  In 
order  to  lessen  the  desire  for  liquor,  and  to  forestall  an  acute  gastritis, 
he  should  be  given  capsicum,  10  minims  of  the  tincture  in  a  glass  of  hot 
milk,  every  two  hours.  Alcohol,  best  in  the  form  of  beer  or  ale,  may 
reasonably  be  given  in  cases  of  this  sort  in  small  quantities.  After 
twenty-four  hours  he  should  be  gradually  worked  up  to  a  normal  diet. 
If  his  sleep  is  interfered  with,  sedatives  should  be  administered. 

If  the  delirium  arises  from  delayed  alcohol  poisoning,  its  treatment 
is  more  complicated  and  less  certain.  If  the  patient  can  be  made  to 
eat  and  to  sleep,  cure  is  practically  sure.  To  obtain  sleep  in  delirium 
tremens  the  sedatives  and  hypnotics  of  the  pharmacopeia  have  been 


DELIRIUM   TREMENS  275 

exhausted.  Opium  in  ordinary  doses  is  ineffectual  and  in  large  doses 
it  may  precipitate  coma.  Chloral  and  paraldehyd  in  such  doses  as 
are  usually  necessary  are  too  depressant,  and  the  same  may  be  said 
of  sulphonal,  though  sulphonal,  30  gr.  every  four  hours,  to  6  doses,  is 
often  used.  Ether  by  inhalation  will  give  the  patient  temporary  respite, 
but  the  delirium  recurs  on  awakening.  Hoffmann's  anodyne  is  a  mild 
sedative  and  at  the  same  time  a  stimulant.  The  sedative  which  is 
ordinarily  employed  is  the  bromids.  These  are  the  least  depressant 
of  the  active  sedatives.  Usually  they  are  given  in  the  form  of  equal 
parts  of  the  bromids  of  sodium,  potassium,  and  ammonium,  on  account 
of  the  depressant  action  of  the  sodium.  This  mixture  may  be  given 
in  doses  up  to  90  gr.  Chloralamid  may  be  given  in  doses  of  20  gr.  every 
four  to  six  hours.  Digitalis  was  at  one  time  held  in  high  repute,  because 
it  slowed  the  pulse  and  quieted  the  circulation  and  in  this  way  aided 
the  system  to  gain  repose.  It  was  formerly  given  in  doses  as  large  as 
a  dram  of  the  tincture  at  a  time.  It  was  found,  however,  in  some 
cases  to  prove  fatal.  It  is  now  frequently  given  in  ordinary  dosage  to 
overcome  the  depressant  action  of  the  large  doses  of  sedative  which  are 
ordinarily  necessary.  Fluidextract  of  ergot  in  doses  of  i  dr.  repeated 
every  four  hours  has  been  recommended.  Capsicum  is  valuable  when 
given  for  the  purpose  of  lessening  the  irritation  of  the  gastric  mucous 
membrane.  Alcohol  in  the  form  of  beer  or  ale  is  useful  as  a  stimulant, 
and  when  given  in  limited  quantity  is  justifiable. 

When  the  delirium  becomes  active,  restraint  becomes  a  necessity. 
The  use  of  a  strait- jacket,  or  even  a  sheet  tied  over  the  body,  is  directly 
injurious,  and  should  not  be  allowed  unless  it  is  absolutely  necessary. 
Under  the  best  form  of  treatment  physical  restraint  of  any  sort  is  usually 
not  considered.  A  good  nurse  should  talk  with  the  patient,  try  to 
amuse  him  and  to  win  his  confidence.  In  this  way  the  patient  can  be 
made  to  forget  most  of  his  fear  and  he  does  not  exhaust  himself  by  his 
endeavors  to  ward  off  danger.  If  he  starts  to  rise,  a  restraining  hand 
can  be  put  upon  his  shoulder  and  he  is  readily  persuaded  to  lie  quiet  in 
bed.  To  be  left  alone  terrifies  him.  He  likes  to  be  in  the  presence  of 
people,  he  likes  cheerful  conversation,  and  he  is  particularly  afraid  of  the 
dark.  Sleep  is  to  be  sought  for  above  all  things,  and  when  it  comes  and 
lasts,  recovery  is  almost  sure.  If  it  is  interrupted,  the  patient  has  a 
succession  of  ineffectual  short  naps  and  no  good  results. 

Next  in  importance  to  sleep  is  nourishment.  If  the  stomach  will 
tolerate  food,  the  prognosis  is  good.  Usually  there  is  no  appetite  and 
food  has  to  be  forced,  or  the  stomach  is  irritable  and  will  not  retain 
the.  food.     In  the  latter  condition  effervescent  waters  and  small  doses  of 


276  POSTOPERATIVE   PSYCHOSES 

calomel  are  of  benefit.     Ice  may  be  given  freely;   milk  and  lime-water, 

malted  milk,  etc.,  should  be  tried.     If  the  stomach  retains  food,  the 

patient  should  be  given  liquids  at  frequent  intervals  and  in  considerable 

quantity.^ 

POSTOPERATIVE   INSANITY 

The  existence  of  mental  disturbances  following  operation  was  noted 
many  years  ago.  In  the  sixteenth  century  Pare  remarked  that  before 
an  operation  the  patient  must  be  in  a  condition  of  spiritual  calm,  in 
order  to  avoid  delirium  and  other  harmful  after-effects.  Dupuytren 
(1819)  was  the  first  to  describe  a  condition  of  mental  excitation,  which 
he  called  delirium  nervosum — coming  on  immediately  following  opera- 
tion. Herzog  (1842)  described  a  case  of  mania  following  an  operation 
for  strabismus,  and  Sichel  (1863)  reported  8  cases  after  cataract  ex- 
traction. These  reports  were  followed  by  many  others,  all  succeeding 
operations  on  the  eye.  Von  Courty,  in  1865,  described  the  first  case 
following  ovariotomy,  and  in  1880  Lossen  and  Furstner  reported  a  case 
after  hysterectomy.  Since  that  date  there  has  developed  a  very  con- 
siderable literature  on  the  subject. 

Occurrence. — Insanity  following  operation  occurs  relatively  not 
often.  Dewey  in  5000  insane  found  only  3  cases  of  insanity  following 
operation  in  persons  previously  of  sound  mind.  It  is  uncommon  also 
in  proportion  to.  the  total  number  of  operations,  various  writers  reporting 
from  I  to  ^  per  cent.  As  to  the  nature  of  the  operations  which  seem 
to  induce  insanity  operations  on  the  genital  organs  in  women  or  men  take 
the  lead,  and  eye  operations  come  next,  though  almost  every  possible 
operation  has  found  a  place  on  the  list.  Rohe,  of  Baltimore,  in  studying 
196  cases  of  postoperative  insanity  etiologically,  found  that  the  condition 
followed  genital  operations  in  65  cases,  cataract  operations  in  35  cases, 
and  various  operations  in  96  cases.  The  preponderance,  as  regards  sex, 
is  about  4  to  I  in  favor  of  women.  This  is  clearly  due  to  the  large 
proportion  of  gynecologic  operations  in  women  as  compared  with  opera- 
tions on  the  genital  organs  in  men,  for  Sears,'  of  Boston,  has  shown 
that  in  operations  common  to  both  sexes  the  proportion  is  about  equal. 

Causes. — A  patient  suffering  mildly  from  delusions  may  be  oper- 
ated upon  without  her  mental  condition  being  appreciated  by  the  surgeon. 
It  is  not  uncommon,  for  instance,  for  a  woman  affected  with  cyclic 
insanity  to  complain  of  vague  abdominal  pains,  or  to  suffer  from  a 
variety  of  symptoms  referable' to  the  genital  tract.  Such  a  one  may 
become  insane  at  the  application  of  the  anesthetic.  Generally  speak- 
ing,  however,  operations  may  be  performed  in  those  frankly  insane 

^  Cheever,  Lectures  on  Surgery,  Boston,  1894,  39. 


POSTOPERATIVE    INSANITY  *  277 

without  detriment,  and  sometimes  even  with  benefit  to  their  mental 
trouble. 

It  may  be  considered,  in  general,  that  the  essential  prerequisite  for 
the  development  of  postoperative  insanity  in  those  previously  of  sound 
mind  must  be  a  neurotic  organization,  predisposed,  either  from  heredi- 
tary taint  or  from  acquired  nervous  instability,  to  become  unbalanced 
in  consequence  of  an  active  disturbing  factor.  This  determining  factor 
may  be  psychic — strange  surroundings,  worry,  vacillation  between  hope 
and  fear,  pain,  anticipation  of  blindness,  sterility,  or  climacteric.  It 
may  be  toxic,  as  the  withdrawal  of  alcohol,  cocain,  or  morphin  in  those 
accustomed  to  their  use.     It  may  be  traumatic,  as  head  injuries. 

Besides  these  preoperative  causes,  we  must  consider  as  important  the 
anesthetic,  especially  if  long  continued,  and  shock,  hemorrhage,  and 
collapse.  In  the  postoperative  stage  we  have  to  consider  pain,  enforced 
isolation,  deprivation  of  light  (in  eye  cases),  deprivation  of  water,  septi- 
cemia, acetonemia,  and  uremia.  Finally,  there  are  various  drugs  which 
may  induce  delirium — iodoform,  atropin,  sodium  salicylate, 

Forms. — There  is  no  special  form  of  mental  disturbance  to  which 
the  name  postoperative  insanity  can  be  applied.  Clinically,  the  term 
encompasses  a  variety  of  psychoses,  which  are  related  to  each  other 
only  in  so  far  as  they  follow  after  a  surgical  operation.  The  condition 
ranges  from  the  transient  delirium  or  mental  confusion  which  may 
follow  immediately  on  the  use  of  any  anesthetic — through  the  drug 
psychoses  attending  the  local  use  of  iodoform,  the  employment  of  colly ri  a 
of  atropin,  or  the  internal  administration  of  sodium  salicylate,  all  of 
which  usually  subside  with  the  withdrawal  of  the  agent — and  acute 
confusional  insanity,  resembling  delirium  tremens,  frequently  due  to 
sepsis  or  toxic  conditions,  which  often  lasts  weeks  or  months,  and  in- 
cludes premature  climacteric  insanity  in  the  form  of  melancholia  fol- 
lowing the  removal  of  the  ovaries,  and  premature  senile  dementia, 
not  infrequently  occurring  after  geni to-urinary  operations  in  the  male. 
The  manifestations  may  be  maniacal,  depressive,  or  paretic.  The 
commonest  type  is  acute  confusional  insanity — outbreaks  of  excitation 
with  confusion  and  hallucinations,  alternating  with  periods  of  stupor, 
coming  on  after  a  prodromal  period  of  nervous  irritability  and  mental 
anxiety.  Sudden  outbreaks  of  violence,  as  in  puerperal  and  alcoholic 
insanity,  occur  uncommonly. 

Prognosis. — If  the  mania  has  developed  slowly  in  a  young  person 
otherwise  of  sound  constitution,  a  perfect  recovery  may  be  usually  ex- 
pected, though  some  patients  die  of  exhaustion.  In  older  persons  and 
patients  suffering  from  grave  organic  disease,  or  weakened  by  alcoholism 


278  POSTOPERATIVE  PSYCHOSES 

or  syphilis,  the  development  of  a  chronic  dementia  is  to  be  feared. 
Recovery,  when  it  takes  place,  is  rapid,  and  leaves  behind  only  a  dim 
recollection  of  the  events  between  the  operation  and  the  return  to  normal. 

Treatment.— In  the  way  of  prophylaxis  everything  should  be 
done  before  operation  to  induce  a  state  of  confidence  and  tranquillity 
of  mind  in  the  patient,  and  to  lessen  the  nervous  shock  of  any  procedure 
which  involves  the  genital  or  geni to-urinary  tract.  Especial  attention 
should  be  paid  if  the  patient  is  known  to  be  "  high  strung,"  has  had  at- 
tacks of  mental  instability,  or  has  a  suspicious  heredity.  In  deciding 
for  or  against  an  operation  of  choice,  the  mental  condition  should  be  an 
important  factor. 

Treatment  should  be  directed  toward  relieving  any  possible  causal 
condition,  septicemia  and  uremia  should  be  combatted,  toxic  agents 
should  be  withdrawn.  The  patient  should  be  kept  in  bed  in  cheerful, 
airy  surroundings;  isolation  is  not  desirable.  He  should  be  kept  clean, 
and  particular  attention  paid  to  forestalling  bed-sores.  His  nutrition 
should  be  well  looked  to;  he  should  be  encouraged  to  eat,  and  stomachics 
and  stimulants  employed  if  necessary.  The  bowels  should  be  kept  free 
with  mild  salines.  Warm  baths  will  usually  suffice  to  control  restless- 
ness and  sleeplessness;  when  hygienic  measures  fail,  opium  or  hyoscin 
becomes  necessary.  Bromids  should  be  avoided,  as  being  too  depress- 
ing. 

Regis  ^  has  reported  success  with  the  use  of  ovarian  extract  in  a 
woman  who  had  had  her  ovaries  removed,  and  A.  T.  Cabot^  reported  a 
case  of  confusional  psychosis  in  which  prompt  improvement  followed 
the  exhibition  of  testiculin. 

References 

Dent,  Jour.  Mental  Sciences,  1889,  xxxv,  i. 

Sears,  Boston  and  Med.  Surg.  Jour.,  1893,  cxx\iii,  642. 

C.  G.  Dewey,  Trans.  Amer.  Medico-Psycholog.  Ass.,  1898,  v,  223. 

Robe,  Amer.  Jour.  Obstetrics,  1898,  xxxix,  324. 

Hurd,  Amer.  Jour.  Obstetrics,  1898,  xxxix,  331:. 

Englehardt,  Deut.  Zeitsch.  f.  Chir.,  1900,  Iviii,  46. 

Menopause. — Mild  psychoses  analogous  to  those  which  some- 
times occur  at  the  climacteric  may  develop  after  destructive  operations 
upon  the  pelvic  organs  in  women.  These  manifestations  are  rarely  of 
sufficient  importance  to  necessitate  treatment.  They  depend  chiefly 
upon  the  apprehension  with  which  most  women  regard  this  natural 
cessation  of  function.     Many  women  look  fonvard  to  the  climacteric 

^  Amer.  Jour.  Insan.,  1893,  1,  345. 

^  Com.  Mass.  Med.  Soc,  1893,  x\i,  657. 


POSTOPERATIVE   INSANITY  279 

with  dread,  because  they  have  seen  or  heard  of  cases  of  mahgnant 
disease  or  of  nervous  prostration  occurring  in  others  at  a  similar  period. 
Others  are  apprehensive  of  a  decrease  in  attractiveness  and  an  early 
senile  decline. 

The  symptoms  which  accompany  this  artificial  menopause  are 
usually  emotional  or  melancholic,  but  they  sometimes  take  the  form  of 
nervous  instability,  accompanied  by  hot  flushes,  vertigo,  and  palpitation. 
Rarely  the  condition  goes  so  far  as  to  cause  a  nervous  breakdown  which 
requires  isolation  and  treatment.  Ordinarily,  whatever  nervous  mani- 
festations arise  are  of  a  temporary  nature,  and  disappear  as  the  patient 
gets  out  of  bed  and  about.  Sometimes  after  removal  of  both  ovaries 
the  patient,  if  she  has  previously  been  thin,  will  become  fleshy.  Usually 
sexual  desire  is  preserved  unimpaired,  although  this  seems  to  vary  with 
the  patient.^ 

^  Walthard,  Psychoneurotic  Climacteric  Phenomena,  Zeit.  f.  Gyn.,  1908,  xxxii,  564; 
D.  H.  Craig,  The  Menopause,  Jour.  Amer.  Med.  Assoc,  1908,  li,  1507. 


CHAPTER  XXXI 

GENERAL  TREATMENT  IN  CONVALESCENCE 

Some  surgeons  make  it  a  practice  to  administer  tonic  and  stimulant 
drugs  during  recovery  from  operation  to  hasten  convalescence.  As  a 
routine,  the  habit  should  be  disapproved.  Patients  come  to  the  surgeon 
in  a  state  of  more  or  less  profound  constitutional  depression  caused  by 
their  surgical  condition,  or  else  they  are  normal  as  regards  general 
health,  and  present  a  condition  which  has  caused  no  constitutional  dis- 
turbance whatever.  In  the  first  case  the  removal  of  the  depressing 
influence  should  be  at  once  followed  by  the  exhibition  of  a  tendency 
toward  a  recovery  of  the  normal  tone  and  physical  well-being;  in  the 
latter  case,  operation  is  a  mere  incident,  and,  except  for  the  effects  of 
anesthesia,  the  balance  of  metabolism  should  not  be  seriously  disturbed. 
Ordinarily,  a  person  who  expects  to  be  restored  to  complete  health  after 
an  operation,  who  has  not  been  sick  long  enough  to  have  lost  his  impulse 
toward  recovery,  will  need  no  artificial  aids  except  cheerful,  comfortable 
surroundings  and  companionship,  a  sufficient  and  proper  diet,  and 
plenty  of  sunlight  and  fresh  air,  if  these  may  be  called  artificial. 

The  treatment  of  patients  in  whom  ultimate  recovery  is  not  expected, 
and  those  whose  spirit  has  been  broken  by  prolonged  illness  or  repeated 
disappointment,  will  depend  on  the  nature  of  the  case  and  the  personal- 
ity of  the  surgeon.  Tonics  and  stimulants  are  indicated  when  they 
will  impress  the  patient  or  sustain  or  improve  his  physical  or  mental 
tone.  Added  to,  and  better  than,  these  is  the  moral  influence  of  an 
energetic,  strong-willed,  and  trusted  physician.  Ordinarily,  surgical 
convalescence  is  comparatively  brief,  and  the  surgeon  is  not  so  likely 
to  have  cast  in  his  way  that  bug-a-boo  of  the  internist — the  "chronic." 
Whenever,  however,  a  surgeon  becomes  convinced  that  he  is  losing  or 
has  lost  the  confidence  of  a  patient  who  is  progressing  slowly,  and  whose 
convalescence  is  likely  to  be  prolonged,  he  will  be  wise  if  he  calls  a  con- 
sultant or  brings  to  his  aid  some  other  fresh  and  outside  agency,  be  it 
psychotherapy,  electrotherapy,  hydrotherapy,  light  or  mechanotherapy, 
the  x-ray,  or  massage.  Such  a  move  will  usually  react  to  the  advantage 
both  of  the  patient  and  the  doctor,  and  it  should  not  be  too  long  post- 
poned. • 

280 


GENERAL  TREATMENT  IN  CONVALESCENCE  281 

The  use  of  morphin  in  suffering  incurables  and  the  use  of  proper 
medicines  in  those  who  have  coincident  disorders  which  require  medical 
treatment,  such  as  malaria  or  syphilis,  is  to  be  taken  as  a  matter  of  course. 
If  any  other  indications  develop  which  require  medication,  they  should 
be  met;  for  instance,  constipation,  nervousness  or  insomnia,  loss  of 
appetite,  impoverished  blood,  remembering,  what  we  have  already  stated, 
that  a  proper  regulation  of  surroundings  and  habit  and  sufi&cient  food 
and  sunlight  will  often  render  drugs  unnecessary. 

Among  the  tonics  and  stimulants  we  will  consider  iron,  strychnin, 
arsenic,  and  alcohol. 

Iron  is  frequently  indicated  to  overcome  the  effects  of  hemorrhage. 
It  is  best  absorbed,  in  surgical  convalescence  at  least,  apparently  not 
from  the  liquid  preparations,  but  in  the  form  of  ferrous  carbonate — Blaud's 
mass.  Direct  measurements  of  the  number  of  red  corpuscles  and  of  the 
hemoglobin  in  an  investigation  which  I  carried  out  in  two  series  of  cases 
showed  a  distinctly  more  rapid  increase  in  both  respects  on  Blaud's 
mass  than  on  reduced  iron  or  several  highly  extolled  liquid  and  pro- 
prietary preparations.  The  Blaud's  mass  should  be  given  either  in 
soft  pills,  not  too  old,  or,  better,  as  a  powder  in  gelatin  capsules. 

Strychnin,  either  in  the  form  of  the  sulphate,  -gV  ^°  4V  S^-'  ^"^'^  °^ 
three  times  a  day,  or  in  the  form  of  tincture  of  nux  vomica,  is  a  standard 
stomachic  and  nerve  stimulant,  and  should  be  given  in  appropriate 
cases,  withheld  at  night,  or  the  dose  diminished,  if  it  leads  to  sleepless- 
ness. 

Arsenic  may  be  given  as  the  trioxid  in  doses  of  y-g-Q-  gr.  after  each 
meal,  or  in  the  form  of  Fowler's  solution,  liquor  potassii  arsenitis, 
3  to  6  minims,  to  be  stopped  at  the  occurrence  of  diarrhea  or  any  other 
symptom  of  poisoning. 

Alcohol  in  the  form  of  bitters  before  meals,  or  ale  or  beer,  undoubt- 
edly has  some  place  in  convalescence,  but  in  case  of  the  slightest  doubt 
as  to  its  appropriateness,  it  should  be  withheld. 

Ouf-of-doors  and  Sunlight. — Nearly  all  that  has  been  said  as  to  the 
value  of  out-of-door  life  and  sunshine  in  surgical  tuberculosis  applies, 
in  my  opinion,  to  the  healing  of  all  wounds  and  to  surgical  convalescence 
in  general.  The  much-vaunted  air  of  the  Engadine  is,  after  all,  only 
pure  air,  and  we  need  not  cross  the  ocean  to  find  that.  It  is  obvious 
that  in  the  presence  of  diseases  of  the  kidneys,  and  in  possibly  certain 
other  special  conditions,  care  must  be  taken  not  to  expose  the  patient 
too  early  to  a  possible  chilling  of  the  skin  in  the  out-of-doors  atmosphere, 
but  in  general  the  respiration  and  all  other  vital  functions  are  stimulated 
by  a  convalescence  spent,  so  far  as  possible,  out-of-doors.     There  is  an 


282  GENERAL   TREATMENT   IN   CONVALESCENCE 

open-air  sanitarium  at  every  door,  from  which  any  surgeon  with  sufficient 
energy  and  originality  can  benefit. 

A  surgical  operation  should  not  be  looked  upon  as  an  experience 
in  disease,  but  rather  only  as  an  affection  of  a  part — an  aggravated  sore 
finger,  as  it  were.  After  an  operation  the  patient  should,  as  soon  as 
possible,  be  surrounded  by  an  atmosphere  of  normahty,  with  rather  the 
spirit  of  the  theoretic  soldier  who  binds  up  his  wounds  and  proceeds. 
The  mental  attitude  to  encourage  is — the  patient  has  not  been  sick,  he 
has  been  wounded. 

It  is  not  a  contradiction  of  this  sentiment  of  returning  to  normal  life 
as  soon  as  possible  to  say  that,  in  the  matter  of  visitors  during  a  surgical 
convalescence,  I  believe  that  the  choice  and  number  of  visitors  should 
be  decided  entirely  by  the  patient,-  and  the  duration  of  their  stay  by  the 
attending  nurse,  if  she  is  a  wise  woman.  Ordinarily,  friends  need  only 
be  told  that  it  is  to  the  patient's  advantage  for  them  to  stay  away  and 
they  do  so. 


CHAPTER  XXXII 

BED-SORES:    CAUSES;  PREVENTION;  TREATMENT 

Decubitus,  or  bed-sore,  is  an  area  of  moist  gangrene  caused  by  pres- 
sure. It  is  most  apt  to  occur  on  the  backs  of  patients  who  are  confined 
in  bed  for  an  extended  period,  but  it  may  occur  wherever  pressure  is 
likely  to  exist  unrelieved  for  any  length  of  time.  On  the  back,  it  occurs 
ordinarily  over  the  bony  prominences  about  the  sacrum  and  on  the 
buttocks.  It  may  occur  also  on  the  heel,  over  the  great  trochanter,  or 
at  the  edge  of  a  splint,  and  the  pressure  of  bed-clothes  upon  the  toes 
may  even  be  sufficient  to  cause  it.  Liability  to  the  occurrence  of  bed- 
sores is  always  increased  in  conditions  which  allow  of  little  or  no  voluntary 
movement  on  the  part  of  the  patient,  especially  in  paralysis.  It  is 
increased  by  the  lack  of  proper  cleanliness  or  the  presence  of  irritating 
secretions,  and  particularly  the  state  of  incontinence  of  urine  or  feces. 
Crumbs  of  bread,  creases  or  folds  in  the  sheet  or  bedgown,  bits  of  string, 
pins,  or  other  extraneous  objects  in  the  bed  will  furnish  ample  cause 
for  the  formation  of  a  bed-sore.  The  absence  of  bed-sores  in  bed-ridden 
patients  is  usually  held  to  be  a  criterion  of  good  nursing. 

The  underlying  cause  of  bed-sores  is  a  lessening  of  the  vitality  of 
the  skin  by  persistent  localized  pressure.  If  the  nutrition  is  withheld 
from  the  cells,  they  slowly  die  and  are  cast  off  in  the  form  of  slough. 
The  first  clinical  manifestation  of  a  bed-sore  is  a  reddening  of  the  skin. 
This  increases  to  a  local  congestion,  which  gradually  becomes  pale  and 
then  bluish.  Finally,  a  line  of  demarcation  forms  and  the  area  sloughs 
away.  This  leaves  an  ulcer  with  a  foul,  ragged  bottom,  which  excretes 
a  thin,  acrid  fluid.  Unless  rehef  is  furnished,  the  ulcer  increases  rapidly 
in  size  and  works  its  way  deeper  into  the  tissues.  Sometimes  an  un- 
treated bed-sore  will  extend  so  as  to  involve  areas  of  considerable 
size  and  lay  bare,  for  instance,  the  entire  sacrum.  Such  ulcers  are  a 
severe  drain  upon  the  vitality  of  the  patient  and  seriously  complicate 
convalescence. 

Any  case  in  which  the  possibility  of  bed-sores  may  arise  should  be 
carefully  watched,  so  that  their  occurrence  may  be  forestalled.  Prophy- 
laxis consists  in  preventing  unrelieved  localized  pressure.  The  bed- 
clothes should  be  kept  clean,  dry,  and  smooth,  and  no  crumbs  or  ex- 

283 


284  bed-sores:  causes;  prevention;  treatment 

traneous  substances  should  be  allowed  to  find  their  way  under  the 
patient.  The  patient's  own  discharges  should  be  looked  out  for  care- 
fully, and  if  there  is  any  moisture  about  the  genitalia,  it  should  be  dried 
and  the  parts  powdered.  Bandages  and  splints  should  be  adjusted 
from  time  to  time.  The  patient  who  is  unable  to  turn  in  bed  should 
have  his  position  changed  frequently  by  an  attendant.  All  bony  promin- 
ences on  the  back  and  points  liable  to  suffer  from  pressure  should  be 
massaged  and  kept  absolutely  dry  and  powdered. 

In  case  redness  appears  over  the  bony  prominences  action  should 
be  at  once  taken  to  distribute  the  pressure  over  a  larger  area  and  thus 
afford  relief.  On  the  back,  this  can  be  accomplished  by  making  a  so- 
called  doughnut  pad  of  oakum  or  tow,  wrapped  in  gauze  bandage,  and 
placing  it  so  that  the  opening  will  come  opposite  the  point  suffering  from 
pressure.  The  same  object  can  be  accomplished  by  means  of  the  rubber 
ring  which  is  inflated  with  air.  If  there  is  pressure  on  the  heel,  as  in  a 
case  of  fracture  or  paralysis,  the  pressure  can  be  removed  in  the  same 
way.  Other  points  which  are  liable  to  become  pressed  upon,  such  as 
the  malleoli,  tibia,  and  head  of  fibula,  in  case  of  splint  or  plaster-of- 
Paris  bandage  being  worn,  should  be  protected  by  careful  padding.  In 
order  to  keep  the  weight  of  the  bed-clothes  off  the  tips  of  the  toes  when 
they  cannot  be  moved  by  the  patient,  a  cradle  of  wire  or  wickerwork 
should  be  employed,  or  a  lo-inch  board  on  edge  between  the  sheets 
along  the  foot  of  the  bed  may  be  used. 

In  all  cases  where  patients  are  badly  emaciated,  or  where  the  neces- 
sity for  lying  in  one  position  will  continue  for  a  long  time,  they  may  be 
put  upon  a  pneumatic  bed,  or  a  water-bed,  which  distribute  the  pressure 
from  the  weight  of  the  patient  over  a  wide  area.  Patients  who  are 
under  treatment  for  fracture  of  the  hip  or  thigh  can  be  handled  con- 
veniently only  when  lying  upon  a  Bradford  (gas-pipe)  frame  or  some 
similar  device.  These  patients  should  be  turned  over  twice  a  day,  and 
any  region  found  subjected  to  pressure  should  be  washed  and  then 
thoroughly  dried.  It  should  then  be  rubbed  gently  with  a  soft  towel, 
so  as  to  improve  the  nutrition,  and,  finally,  the  skin  should  be  powdered 
with  some  emollient  powder,  such  as  zinc  oxid  and  starch  or  stearate 
of  zinc.  The  use  of  alcohol  or  spirits  of  camphor  will  render  the  skin 
more  resistant  and  less  hable  to  ulceration,  and  the  same  ts  true  of  the 
saturated  solution  of  picric  acid  or  compound  tincture  of  benzoin. 
Sometimes  a  generous  dressing  of  absorbent  cotton,  held  in  place  by 
collodion,  will  serve  to  protect  a  small  area  of  pressure  hyperemia,  or 
the  skin  may  be  painted  direcdy  with  collodion  or  covered  with  adhesive 
plaster. 


bed-sores:  causes;  prevention;  treatment  285 

When  the  bed-sore  has  formed,  the  part  should  immediately  be  re- 
lieved of  all  pressure  by  turning  the  patient  into  another  position  per- 
manently, or  by  the  use  of  the  ring  cushion  or  water-bed.  Dry  dressings 
are  to  be  preferred  unless  slough  occurs,  in  which  case  the  patient  should 
be  turned  upon  his  face  and  moist  applications  frequently  applied. 
For  these  dressings,  nothing  is  so  good  as  chlorinated  soda  and  myrrh. 
The  separation  of  the  slough  in  deep-lying  ulcers  is  usually  tedious,  and 
it  may  often  be  hastened  by  the  use  of  a  digestant,  such  as  enzymol,  or  by 
clipping  it  away  with  scissors.  Hydrogen  dioxid  is  also  of  account 
in  case  sloughing  occurs.  After  the  slough  has  separated  and  the  ulcer 
presents  a  granulating  surface,  skin-grafting,  after  the  Reverdin  method, 
may  be  resorted  to  with  advantage.  Otherwise  some  ointment,  such 
as  ichthyol  or  scarlet  red^  (8  per  cent.) ,  may  be  relied  upon.  Stimulation, 
nourishment,  and  sleep  are  all  valuable  adjuvants  in  treatment. 

^  J.  S.  Davis,  Amer.  Surg.,  1910,  ii,  40. 


CHAPTER  XXXIII 

FOREIGN   BODIES   LEFT   IN  THE  ABDOMINAL   CAVITY 

Although  this  accident  is  not  a  title  to  greatness,  it  is  said  that 
every  great  surgeon  has  had  it  happen.  It  is  certain  that  foreign  bodies 
have  been  left  in  the  abdominal  cavity  much  more  often  than  has  been 
reported — first,  because  of  cases  ending  fatally  without  autopsy,  and, 
second,  because  surgeons  are  not  likely  to  publish  such  experiences. 
The  most  complete  recent  papers  on  the  subject  are  by  Schachner  in 
1901  ^  and  F.  Neugebauer." 

Neugebauer  collected  109  cases  of  foreign  bodies  left  in  the  abdomen 
and  Schachner  collected  155  cases,  including  in  this  number  the  cases 
collected  by  Wilson  and  Neugebauer.  In  Neugebauer's  collection  of 
cases  there  are  31  instances  of  sponges  left  in  and  19  cases  where  artery 
forceps  were  overlooked  and  left  behind.  Probably  every  active  surgeon, 
at  one  time  or  another,  comes  across  cases  which  represent  careless 
technique  on  the  part  of  some  one  else.  For  instance,  I  have  recently 
seen  a  case  where,  four  months  after  a  patient  left  the  hospital  for  a 
nephrectomy,  a  gauze  strip  a  yard  long  was  removed  through  a  small 
sinus  which  had  persisted  in  the  scar  since  the  operation.  I  have  also 
removed  fragments  of  glass,  remnants  of  a  broken  irrigation  tip,  from  a 
prostate,  and  an  entire  fenestrated  rubber  drainage-tube  from  a  sinus 
which  led  into  a  deep-seated  ischiorectal  abscess.  A  case  is  on  record  ^ 
where  a  surgeon  after  a  celiotomy  noticed  that  he  had  lost  a  seal  ring. 
The  patient  some  time  later  was  operated  upon  through  the  vagina  by 
a  second  surgeon,  who  extracted  the  ring.  Imagine  the  state  of  mind 
of  the  first  surgeon  when  his  former  patient  paid  him  a  call  for  the  pur- 
pose of  restoring  his  property. 

Symptoms. — The  symptoms  that  follow  the  retention  of  a 
foreign  body  in  the  abdomen  will  depend  upon  the  nature  of  the  body, 
the  region  in  which  it  is  situated,  and  whether  or  not  sepsis  is  present. 
If  an  instrument  has  been  left  behind  after  a  clean  celiotomy,  it  has  been 
shown  by  several  instances  that  tlie  patient  may  suffer  very  little  in- 

^  Ann.  Surg.,  1901,  xxxiv,  499. 

^  Monats.  f.  Gynak.,  1900,  xi,  821. 

^  W.  J.  S.  McKay,  Care  of  Section  Cases,  p.  561. 

286 


SYMPTOMS  287 

convenience  for  weeks  or  months;  indeed,  it  has  happened  that  the 
occurrence  has  not  come  to  light  until  after  an  autopsy  for  some  inter- 
current affection.  Usually,  however,  sooner  or  later,  the  foreign  body 
sets  up  an  irritation,  and  becomes  the  source  of  an  abscess  which  causes 
a  fistulous  opening,  through  which  it  is  finally  discharged  by  way  of  the 
vagina  or  bowel,  into  the  bladder,  or  even  through  the  abdominal  wall. 
Accompanying  this  process  there  is  apt  to  be  obscure  abdominal  pain, 
sometimes  with  symptoms  of  incomplete  obstruction  and  slight  fever. 
Rest  and  a  limited  diet  will  bring  temporary  relief,  but  the  symptoms 
are  likely  to  recur  soon  after  the  patient  gets  up  and  about.  There  may 
occur  a  sudden  exhibition  of  symptoms  which  will  lead  to  an  immediate 
exploratory  operation,  when  the  true  cause  will  be  disclosed,  or  else  the 
symptoms  will  continue  indefinitely  with  remissions  until,  after  a  flareup, 
they  subside  for  good  and  the  foreign  body  will  be  passed.  If  the  case 
is  septic  at  the  start,  there  are  immediately  evident  the  symptoms  of 
general  or  localized  peritonitis  or  abscess. 

Neugebauer,  in  his  summary  of  the  fate  of  the  cases  in  which  forceps 
were  left  behind,  shows  that  6  died  almost  immediately  after  the  opera- 
tion of  sepsis  and  i  after  a  second  operation,  performed  some  months 
later  for  the  removal  of  the  foreign  body.  In  three  cases  the  forceps 
were  expelled  spontaneously  per  anum — i  four  years,  i  nine  months,  and 
I  ten  months  after  operation.  In  i  case  the  forceps  worked  through 
into  the  bladder.  In  2  cases  they  were  discharged  through  abscesses 
in  the  abdominal  wall.  In  i  case  the  artery  forceps  were  found  in 
Douglas'  culdesac  before  closure  of  the  abdominal  wound.  In  2  cases 
the  loss  of  the  forceps  was  noted  immediately  after  the  closure  of  the 
wound,  and  they  were  recovered  before  the  patient  was  removed  from 
the  operating  table.  In  4  cases  a  subsequent  abdominal  section  was 
required  for  their  recovery  from  three  months  to  two  years  after  operation. 

When  a  sponge  or  a  piece  of  gauze  has  been  left  behind,  recovery  is 
retarded  seriously,  especially  if  the  case  is  septic.  If  the  patient  does 
not  die,  the  presence  of  gauze  will  sooner  or  later  give  rise  to  an  abscess 
or  a  sinus.  In  rare  instances  a  piece  of  gauze  has  been  known  to  have 
been  retained  without  giving  rise  to  symptoms.  In  some  cases  the 
gauze  ulcerates  into  the  bowel  and  is  discharged  by  rectum. 

In  31  cases  where  gauze  sponges  were  left  behind  death  occurred  in 
7.  The  gauze  was  discharged  by  the  rectum  in  10  cases,  the  time  vary- 
ing from  two  days  to  twelve  years  after  the  operation.  A  second  ab- 
dominal section  was  done  in  4  cases,  and  in  the  others  the  gauze  was 
discharged  through  intestinal  fistulas.     In  2  cases  the  sponges  were 


2S8  FOREIGN   BODIES   LEFT   IN   THE   ABDOMINAL   CAVITY 

missed  before  the  wound  was  closed.  In  3  cases  the  wound  was  re- 
opened before  the  patient  left  the  table;  in  3  cases  the  wound  was  re- 
opened in  twenty-four  hours;  in  i  a  sponge  was  discharged  five  months 
after  operation  through  an  abscess  in  the  abdominal  wall.  In  19  cases 
sponges  were  discovered  at  autopsy. 

Neugebauer's  collection  of  cases  shows  that  58  per  cent,  of  the 
patients  recovered  and  42  per  cent.  died.  Some  of  the  deaths  must  be 
referred,  not  to  the  foreign  body,  but  to  sepsis.  If  the  case  is  a  clean 
one,  the  retention  of  a  pair  of  forceps  or  a  piece  of  gauze  in  the  abdominal 
cavity,  while  a  serious  accident  because  of  the  fistulae  and  abscesses 
likely  to  be  formed  sooner  or  later,  it  is  not  to  be  regarded  as  an  accident 
that  is  likely  to  lead  to  an  immediate  fatal  result. 

If  the  foreign  body  is  practically  aseptic  in  its  nature,  the  tendency 
is  for  it  to  become  enveloped  in  a  capsule  of  fibrous  exudate,  and  the 
isolation  is  still  further  carried  on  by  adhesions  between  the  surrounding 
organs.  Thus  encapsulated,  it  may  remain  quiescent  for  months  or 
years,  or  its  presence  may  lead  to  suppuration  and  the  foreign  body  may 
be  -discharged  through  the  fistulous  tract,  which  may  communicate  with 
the  surface,  the  bladder,  the  bowel,  or  the  vagina.  When  it  enters 
the  bowel,  complete  obstruction  of  the  bowel  may  occur  or  a  fecal  fistula 
may  form.  It  has  happened  that  a  pair  of  forceps,  free  in  the  abdominal 
cavity,  has,  by  a  sudden  movement,  been  violently  driven  into  a  large 
blood-vessel  and  caused  the  immediate  death  of  the  patient,  active  and 
without  symptoms,  several  months  after  the  operation. 

Prophylaxis. — No  sponges  should  be  at  hand  during  a  celiotomy. 
For  abdominal  work  gauze  should  be  folded  in  the  form  of  strips  suf- 
ficiently long  so  that  an  end  of  3  to  6  in.  may  be  allowed  to  hang  out 
through  the  wound.  To  this  end  a  hemostat  should  be  applied  by  the 
first  assistant  as  soon  as  the  strip  has  been  introduced.  Some  surgeons 
use  strips  to  the  ends  of  which  a  piece  of  tape  6  in.  long  is  sewn,  and 
to  this  tape  the  hemostat  is  fastened.  This  allows  many  strips  to  be 
introduced  into  the  abdomen  without  crowding  the  wound.  As  soon 
as  the  strip  is  soiled  it  should  be  thrown  on  the  floor,  and  the  operating 
field  should  be  kept  free  of  strips  that  are  not  at  that  moment  in  use. 
No  strips  should  ever  be  allowed  to  be  cut  in  two.  This  interferes  with 
the  sponge  count,  if  the  surgeon  desires  a  sponge  count,  and  a  cut  strip 
is  always  more  readily  left  behind  than  a  strip  which  is  kept  entire. 
The  strict  observance  of  care  in  these  details  will  render  sponge  counts 
unnecessary. 

The  importance  of  exercising  proper  care  in  preventing  this  un- 
fortunate accident  can  be  emphasized  in  no  better  way  than  by  citing 


OPERATION  289 

a  characteristic  case.^  A  surgeon  of  many  years'  experience  operated 
upon  plaintiff  for  ovaritis.  The  patient  did  not  respond  by  the  expected 
recovery,  but  she  grew  worse,  and  thirty  days  later  it  was  discovered 
through  a  part  of  the  original  opening  made  in  the  abdomen  that  some 
foreign  substance  was  lying  near  the  surface,  which  upon  being  removed 
was  discovered  to  be  one  of  the  surgical  sponges  used  at  the  operation. 
It  was  incrustated  and  saturated  with  foul-smelhng  pus.  After  its 
removal  the  patient  improved  in  health,  but  there  was  left  a  sinus  which 
it  was  claimed  had  developed  into  a  fecal  fistula. 

"Many  of  the  physicians  testifying  on  behalf  of  the  defendent  said 
that  the  best  of  surgeons  left  a  sponge  or  some  foreign  substance  in  the 
bodies  of  their  patients  in  performing  similar  operations.  It  was  argued 
from  this  that,  as  the  highest  degree  of  skill  and  care  was  not  exempt 
from  the  commission  of  such  accidents,  a  similar  lapse  by  the  defendant 
was  not  at  least  other  than  ordinary  care,  but  that  did  not  follow;  be- 
cause all  men  are  sometimes  careless  does  not  relieve  any  man  from  the 
legal  consequences  of  his  careless  act;  but,  even  then,  it  was  for  the  jury 
to  say  whether  the  defendant  exercised  the  degree  of  care  in  the  case 
which  ordinarily  prudent  and  skilled  surgeons  who  practise  in  similar 
localities  usually  exercised  in  such  matters."  The  verdict — a  Judgment 
for  $3500  for  the  plaintiff — ^was  accordingly  confirmed  by  the  Court  of 
Appeals. 

Operation. — If  we  discover  immediately  that  a  sponge  or  a  pair 
of  forceps  has  been  left  behind,  we  should  at  once  proceed  to  open  the 
abdomen,  unless  the  patient  is  suffering  from  great  shock,  when  we  may 
postpone  the  operation  for  some  hours  until  the  patient  has  rallied.  If 
the  case  has  been  a  clean  one  and  the  patient  is  very  w-eak,  we  need  not 
interfere  for  two  or  three  days.  If  the  case  is  septic,  we  should  act  as 
soon  as  possible.  If  a  vaginal  examination  shows  a  foreign  body  in 
Douglas's  pouch,  an  incision  in  the  posterior  fornix  is  preferable  to  open- 
ing the  abdominal  wall. 

In  infected  wounds  a  retained  foreign  body  of  whose  presence  we  are 
ignorant  must  lead  to  prolonged  suppuration  without  very  obvious 
cause.  Perinephric  abscesses  and  pelvic  abscesses,  and  occasionally 
appendix  abscess,  may  give  rise  to  a  copious  discharge  of  pus.  After 
a  period  prolonged  to  weeks,  if  this  suppuration  goes  on  without  definite 
diminution  in  quantity,  or  if  the  excursions  of  temperature  continue, 
the  existence  of  a  foreign  body  should  be  considered.  One  should, 
from  day  to  day,  explore  the  depths  of  the  sinus  with  a  metal  crochet 

^  Jour.  Amer.  Med.  Assoc,  1909,  liii,  1229.     Court  of  Appeals  of  Kentucky,  118, 
S.  W.  R.,  339. 
19 


29°  FOREIGN   BODIES   LEFT   IN   THE   ABDOMINAL   CAVITY 

hook,  and  hope  therewith  to  catch  into  the  meshes  of  gauze  or  the  loop 
of  silk  or  other  non-absorbable  suture  if  such  has  been  used.  If,  how- 
ever, a  definite  abscess  collect  in  the  depths  of  a  wound,  a  second  opera- 
tion, which  may  frequently  be  done  in  the  bed  under  primary  anesthesia, 
should  open  it  freely  and  give  opportunity  for  exploration  and  removal 
of  the  cause  if  it  be  a  foreign  body. 


CHAPTER  XXXIV 

POSTOPERATIVE  HERNIA  j   ADHESIONS 

POSTOPERATIVE   HERNIA 

After  any  celiotomy  there  exists  a  possibility  of  the  occurrence  of 
postoperative  ventral  hernia.  It  occurs  most  frequently  after  median 
line  incisions,  particularly  at  the  lower  end  of  the  wound,  below  the 
umbilicus,  and  just  over  the  pubes,  where  the  pressure  of  the  abdominal 
contents  is  greatest  and  strain  most  likely  to  be  felt.  It  is  not  infrequent 
after  operations  on  the  appendix,  particularly  operations  on  appendix 
abscess,  and  in  cases  where  the  muscle-splitting  or  McBurney  incision 
is  not  used.  With  the  commonly  used  right  rectus  incision  hernia  may 
be  expected  to  occur,  according  to  statistics,  in  about  3  per  cent,  of  un- 
drained  cases,  12  per  cent,  where  a  drainage-tube  was  left  in,  and  20 
per  cent,  where  the  wound  was  left  wide  open.  Hernia  is  apt  to  occur 
also  in  lateral  incisions  for  extensive  drainage,  as  in  peritonitis,  and  it 
recurs  after  operations  for  hernia,  either  on  afccount  of  sepsis  in  the 
wound,  poor  technique,  insufficient  musculature,  or  imprudent  post- 
operative care.  It  may  be  immediate,  resulting  from  a  rupture  of  the 
abdominal  wound  during  coughing,  straining,  or  careless  transportation, 
or  it  may  take  months  or  even  years  to  develop.  It  may,  however,  be 
fairly  estimated  that  one-half  make  their  appearance  within  the  first 
year. 

The  occurrence  of  postoperative  hernia  depends,  first,  on  sepsis. 
Sometimes  the  surgeon  must  assume  the  responsibility  for  infection; 
at  other  times  suppuration  is  unavoidable.  Other  things  being  equal, 
the  longer  the  suppuration  continues,  the  greater  the  tendency  to  hernia. 
Particularly  is  to  be  condemned  the  too  persistent  use  of  the  drainage- 
tube. 

Second  to  be  considered  is  the  abdominal  wound.  The  longer  the 
incision,  the  greater  the  likelihood  of  postoperative  hernia.  Median 
line  incisions  are  more  prone  to  develop  herniae  than  are  right  rectus 
or  flank  incisions.  An  incision  in  which  the  various  structures  are 
separated  along  their  own  line  of  cleavage,  so  that  they  will  come  together 
more  naturally,  and  are  not  divided  along  the  same  plane,  so  that  one 
layer  will  buttress  the  opening  in  the  next,  is  ideal  from  this  point  of 

291 


292  POSTOPERATIVE   HERNIA:   ADHESIONS 

view.  Naturally,  the  median  line  incision,  which  traverses  only  one 
layer  of  fascia  and  no  muscle,  and  in  which  reliance  must  be  placed  en- 
tirely upon  the  edge-to-edge  union  of  this  poorly  healing  tissue,  and 
where  there  is  no  reinforcing  action  of  aponeurosis  or  muscle  to  take  off 
the  strain  or  keep  the  wound  closed,  is  just  the  opposite.  The  incision 
recently  introduced  by  Pfannensteil  has  demonstrated  its  practicability 
where  the  median  incision  is  ordinarily  indicated,  and,  theoretically, 
it  should  overcome  the  objections  of  the  older  methods.  It  consists  of 
a  transverse  incision,  slightly  concave  upward,  just  over  the  pubes, 
through  skin  and  superficial  fascia.  The  aponeuroses  are  divided 
transversely,  and  the  rectus  muscle,  to  one  side  of  the  median  line, 
separated  vertically.  The  contraction  of  the  muscle  brings  together 
the  cut  edges  of  the  aponeurosis.  The  technique  is  frequently  modified 
to  mean  a  transverse  skin  incision,  and  then  the  ordinary  right  or  left 
rectus  incision,  just  to  one  side  of  the  median  line.  This  gives  good 
pelvic  exposure,  usually  heals  rapidly  in  undrained  cases,  and  with 
lessened  liabihty  to  hernia. 

Third,  is  the  matter  of  wound  closure.  The  peritoneum,  even,  cannot 
afford  to  be  neglected,  since,^  after  operation,  where  for  any  reason  the 
peritoneum  has  failed  to  unite,  there  may  be  protrusion  of  gut  im- 
mediately beneath  the  skin  without  sac  formation.  It  has  become 
generally  accepted  that,  in  sewing  up  an  abdominal  wound,  homxologous 
structures  should  be  brought  together.  This  is  the  basis  of  our  modern 
technique,  the  so-called  tier  or  layer  suture.  Lluscle  is  united  to  muscle 
and  fascia  to  fascia,  and  no  foreign  structure  is  alloAved  to  interpose. 
It  is  of  undoubted  advantage,  also,  if  in  suturing  aponeurosis  or  fascia 
the  structures  be  overlapped  ^  in.  or  so,  instead  of  being  brought  edge 
to  edge.  This  gives  a  broader  surface  for  the  exercise  of  plastic  repair 
and  a  consequently  much  firmer  union.  This  technique  brings  together 
structures  of  a  like  nature  firmly  but  without  tension.  It  has  the  minor 
disadvantage  of  creating  potential  dead-spaces  between  layers.  The 
great  disad\'antage  of  the  through-and-through  suture  is  the  necessity 
of  drawing  the  sutures  tightly  in  order  to  maintain  adequate  apposition, 
particularly  in  thick  abdominal  walls,  and  the  subsequent  liability  to 
suppuration.  Noble  ^  states  that  hernia  occurs  with  the  through-and- 
through  suture  in  about  5  per  cent,  of  the  cases,  whereas  after  the  tier 
suture,  in  America,  hernia  occurs  in  not  more  than  i  per  cent.  If  sup- 
puration occurs  in  a  wound,  hernia  may  follow,  no  matter  which  method 

^  De  Garmo,  Abdominal  Hernia,  Its  Diagnosis  and  Treatment,  Phila.,  1907. 
^  The  Abdominal  Wound,  its  Immediate  and  Afier-care,  Amer.  Jour.    Obst.,  1907, 
Ivi,  328. 


POSTOPERATIVE   HERNIA:    SYMPTOMS  293 

we  employ;  however,  the  smaller  the  opening  and  the  shorter  the  dura- 
tion of  drainage,  the  less  the  likelihood  of  hernia. 

Finally,  it  is  important  to  consider  the  etiologic  influence  of  after- 
care. It  must,  first  of  all,  be  accepted  candidly  that  scar  tissue,  even 
of  aseptic  healing,  rarely  has  the  strength  of  the  tissue  which  it  is  designed 
to  replace.  It  is  extremely  likely  to  stretch,  unless  it  is  bolstered  by 
adequate  muscles,  under  any  form  of  strain,  particularly  in  the  case  of 
patients  of  sedentary  habits  who  gain  weight  rapidly  after  operation. 
It  must  be  remembered,  also,  that  the  plastic  processes  concerned  in  the 
repair  of  an  abdominal  incision  take  place  under  conditions  of  unrest 
and  irregular  strain,  from  respiration,  vomiting,  etc.,  not  present  in  many 
other  parts  of  the  body.  In  those  with  ill-developed  muscles  the  scar 
tissue  yields  to  the  strain  of  crying,  coughing,  and  defecation,  and  hernia 
results.  Whereas,  this  is  less  likely  to  occur  in  early  life,  it  is  quite  prone 
to  take  place  later  on,  when  fat  has  accumulated  and  the  general  muscular 
tone  of  the  body  is  falling  off.^  The  modern  tendency  of  getting  patients 
out  of  bed  early  is  likely  to  increase  the  tendency  to  hernia.  The  use 
of  swathes  will  be  considered  in  the  next  chapter. 

Symptoms. — The  symptoms  of  postoperative  hernia  are  usually 
never  marked,  and  depend  on  the  site  and  nature  of  the  hernia  and  its 
manner  of  occurrence.  If  the  hernia  is  of  gradual  development,  it  at  no 
time,  practically,  presents  noticeable  symptoms,  such  as  pain,  although 
there  is  likely  to  be  a  more  or  less  constant  feeling  of  strain  or  soreness. 
If  the  hernia  is  in  the  nature  of  a  general  bulge,  this  soreness  may  be 
marked  during  activity,  particularly  if  the  patient  wears  no  support. 
If  the  bowel  or  omentum  comes  out  through  a  small  opening,  such  as 
that  left  by  a  drainage-tube,  the  condition  will  simulate  that  of  an  in- 
guinal hernia,  and  there  may  be  occasional  attacks  of  sharp,  colicky 
pain,  as  knuckles  of  bowel  or  omentumi  get  temporarily  caught. 

Frequently  the  patient  is  altogether  unconscious  of  the  fact  that 
he  has  a  hernia.  Habitual  constipation  generally  accompanies  large 
ventral  herniae. 

The  means  of  prophylaxis  have  already  been  dwelt  upon.  Summed 
up,  it  consists  in  making  an  incision  which  will  allow  of  as  complete  a 
return  to  the  original  integrity  of  the  abdominal  wall  as  possible,  and 
sewing  it  up  so  that  this  return  to  normal  conditions  is  encouraged  and 
facilitated;  in  shunning  possibilities  of  sepsis,  and  in  guarding  the 
convalescence  so  that  no  strain  is  put  upon  the  scar  until  it  is  ready  to 
bear  it. 

^  See  Barker,  Causes  and  Operative  Treatment  of  Umbilical  and  Ventral  Hernia,  The 
Practitioner,  1908,  i,  149. 


394  POSTOPERATIVE   HERNIA:   ADHESIONS 

Treatment. — A  hernia  occurring  early  in  the  convalescence 
should  be  treated  by  strapping  the  edges  of  the  wound  closely  together 
by  means  of  adhesive  plaster  straps.  Straps  properly  adjusted  should 
relieve  the  healing  scar  of  all  possibility  of  further  strain,  and  thus  prevent 
stretching  and  consequent  thinning  out  of  the  scar  tissue.  As  soon  as  the 
patient  is  up  and  about,  a  swathe  should  be  fitted  and  worn  until  an 
operation  is  decided  upon,  or  permanently,  if  operation  is  contra- 
indicated.  No  truss  or  other  apparatus  should  be  worn  which  provides 
a  pad  to  exert  pressure  on  the  region  of  the  scar,  for  this  will  lead  to 
atrophy  and  certain  increase  in  the  extent  of  the  hernia. 

Operation  is  usually  postponed  until  healing  is  complete  and  the  scar 
has  reached  its  maximum  degree  of  contraction.  After  this  it  should 
not  be  put  off  too  long,  on  account  of  the  tendency  for  the  formation  of 
adhesions  of  viscera  to  the  scar.  Mere  end-to-end  approximation  of  the 
freshened  edges  of  the  aponeurosis  which  form  the  ring  does  not  suffice— 
the  fascia  must  be  cleared  back  and  the  edges  made  to  overlap.  The 
flap  may  be  transverse  or  longitudinal,  as  best  suits  the  mechanical 
requirements  of  the  situation.  If  there  is  a  redundancy  of  skin-flap, 
the  excess  may  be  removed  by  including  it  in  an  elliptical  incision. 
In  order  to  better  the  chances  for  healing  of  the  new  wound  without 
hernia  formation  by  relieving  the  intra-abdominal  tension  it  is  wise 
to  reduce  the  bulk  of  the  \ascera  by  remo\ang  such  omentum  as  is 
adherent  to  the  sac  en  bloc.  This  is  desirable  also  if  the  omentum  has 
to  be  handled,  or  is  oozing  as  a  result  of  the  manipulations  neces- 
sary for  separation  of  adhesions.  The  operation,  in  wide  median  line 
hemise,  is  usually  so  planned  that  the  elliptical  area  of  skin,  the 
underlying  fat,  the  sac,  and  the  tied-off  omentum  which  is  adherent  are 
removed  in  one  mass. 

ADHESIONS 

The  peritoneum  has  the  property  of  sticking  together  and  forming 
adhesions  when  infected,  irritated,  or  injured.  This  is  the  property  by 
which  it  responds  to  protect  itself  against  perforation,  to  limit  septic 
processes,  and  to  protect  the  organism  against  general  infection.  The 
peritoneum  serves  the  purpose  most  intelligently;  for  instance,  when 
it  has  tried  in  vain  to  prevent  perforation  of  a  gastric  or  intestinal  ulcer, 
by  reinforcing  the  viscus  at  this  site,  it  limits  the  abscess  which  results 
by  forming  a  circumscribed  pocket  for  it  to  pour  into,  and  after  a  time 
provides  for  its  oudet  by  directing  a  second  perforation  into  the  intes- 
tine or  externally.  Accordingly,  we  frequently  rely  upon  this  function 
of  the  peritoneum  for  aid  in  overcoming  disease  processes. 


ADHESIONS 


295 


This  useful  property  has,  however,  another  aspect.  Adhesions  may 
arise  after  dean  operative  procedures  in  cases  where,  to  the  surgeon's 
understanding,  they  can  serve  no  useful  purpose.  In  other  cases, 
where  they  have  been  of  valuable  assistance,  they  may  persist  after 
their  usefulness  is  ended  and  interfere  with  the  normal  function  of 
the  viscera  to  such  an  extent  that  the  patient,  freed  from  his  primary 
trouble,  may  have  to  be  operated  for  relief  from  his  adhesions.  More- 
over, adhesions  may  stretch  into  bands,  under  the  influence  of  the 
intestinal  activity,  and  they  are  always  a  potential  cause  of  acute  ob- 
struction. 

The  chief  source  of  postoperative  adhesions  is  infection;  this  may 
vary  from  a  mild  inflammation  to  a  virulent  sepsis,  but,  generally  speak- 
ing, the  greater  the  degree  of  suppuration,  the  more  extensive  will  be 
the  adhesions.  Imperfect  hemostasis  may  cause  adhesions;  the  blood 
which  oozes  out  clots  and  organizes.  Another  important  source  is 
the  leaving  behind  of  raw  surfaces,  without  peritoneal  covering,  either 
from  accidental  tears  or  necessary  stripping  of  the  peritoneum.  Opera- 
tive irritation  acts  similarly,  by  causing  a  necrosis  of  the  delicate  endo- 
thelial layer  which  constitutes  the  peritoneum.  This  irritation  may  be 
chemical,  as  by  the  use  of  antiseptic  solutions  in  washing  out,  or  me- 
chanical, from  injudicious  use  of  retractors,  rough  or  excessive  manipu- 
lation, the  use  of  dry  gauze  sponges,  the  undue  exposure  of  the  viscera 
to  dry  or  cold  air,  and  the  use  of  unprotected  gauze  drainage.  Gauze, 
indeed,  is  frequently  used  when  we  are  desirous  of  encouraging  and 
training  adhesion  formation  to  serve  our  purposes  in  septic  cases. 

Wherever  the  peritoneum  is  irritated,  cut,  inflamed,  or  denuded 
from  whatever  structure  it  invests,  there  is  an  immediate  outpouring  of 
more  or  less  bloody  lymph.  This  coagulates,  and  becomes  organized 
into  granulation  tissue,  which  finally  becomes  fibrous.  Any  organ  or 
structure  which  comes  into  contact  with  the  area  so  covered  with  exudate 
or  granulation  tissue  is  extremely  likely  to  become  adherent  to  it  within 
a  few'  hours,  particularly  if  it  has  itself  undergone  similar  inflammation 
or  injury.  Thus,  the  omentum  practically  always  becomes  adherent 
to  an  abdominal  incision  during  the  process  of  healing.  This  is  salu- 
tory,  in  so  far  as  it  prevents  the  formation  of  adhesions  directly  between 
intestine  and  scar,  and  it  is  .usually  intentionally  promoted  by  bringing 
down  the  omentum  to  cover  the  intestine  before  closing  an  abdominal 
incision.  -  Adhesion  formations  of  this  type  tend  to  elongate  and  stretch 
under  the  influence  of  the  normal  motility  of  the  organs  which  they 
connect.  Sometimes  the  bands  which  result  are  firm  enough  to  be 
the  source  of  danger  from  intestinal  obstruction.     Operations  in  the  lower 


296  POSTOPERATIVE   HERNIA:   ADHESIONS 

peritoneal  cavity  and  pelvis  are  more  likely  to  be  followed  by  acute 
obstruction  than  operations  on  the  stomach  and  gall-bladder,  for  it  is 
into  the  lower  portion  of  the  peritoneal  cavity  that  the  intestine  naturally 
gravitates.  The  omentum,  moreover,  may  become  adherent  at  several 
points,  leaving  loops  through  which  knuckles  of  intestine  may  be  wedged 
and  caught.  Bands  usually  tend  to  attenuate  and  gradually  disappear. 
Sometimes  there  is  a  massive  outpouring  of  exudate  instead  from  some 
generalized  cause,  and  deposits  of  fibrin  cover  intestine  and  parietes 
in  thick  layers,  which,  organizing,  unite  each  to  each,  and  bind  together 
the  viscera  in  a  mass  of  adhesions.  This  matting  together  of  intestine 
is  less  likely  to  be  followed  by  obstruction  than  is  the  band  formation, 
and  it  likewise  tends  to  attenuate  and  may  in  time  disappear  entirely. 

The  formation  of  adhesions,  and  their  elimination  when  once  formed, 
seems  to  depend  in  a  certain  measure  upon  the  individual  peculiarity 
of  the  patient.  In  some  peritoneal  cavities  we  find  that  very  slight 
provocation  has  been  followed  by  the  formation  of  extensive  or  even 
universal  adhesions,  and  sometimes,  on  the  other  hand,  we  find  very 
slight  adhesion  formation  after  serious  bacterial  inflammation.  In 
the  same  way  in  some  persons  extensive  adhesions  will  apparently  take 
care  of  themselves  and  give  no  trouble  after  operation,  and  in  others 
mild  adhesion  formation  after  a  clean  celiotomy  may  cause  symptoms 
of  so  aggravated  a  type  as  to  make  necessary  surgical  interference. 

The  operation  which  most  frequently  gives  rise  to  trouble  from 
adhesions  is  appendectomy.  It  is  practically  impossible  to  perform 
an  operation  upon  the  appendix  or  gall-bladder,  for  instance,  with 
the  assurance  of  complete  bacteriologic  sterility.  In  interval  cases 
the  adhesion  formation  is  slight;  in  acute  or  septic  cases  the  intestines 
may  be  matted  together,  and  the  lower  end  of  the  ileum  may  be  so 
compressed  as  to  interfere  seriously  with  its  functioning.  Similar  re- 
sults may  occur  after  operations  in  the  female  pelvis.  Another  frequent 
source  of  origin  of  postoperative  adhesions  is  operation  upon  the  gall- 
bladder or  bile-passages.  Bands  are  likely  to  constrict  the  ducts  so  as 
to  interfere  with  normal  drainage  or  to  limit  the  functions  of  the  gall- 
bladder. Adhesions  after  gastro-enterostomy  may  be  the  cause  of 
protracted  bilious  vomiting. 

The  symptoms  arising  from  postoperative  adhesions  may  be 
either  insidious  or  fulminating.  While  it  is  true  that  intestinal  adhesions 
may  exist  and  the  patient  suffer  no  impairment  of  health,  nevertheless 
they  are  the  frequent  cause  of  digestive  disturbances,  ill-defined  or 
sharply  localized  abdominal  pain  and  soreness,  and  sometimes  acute 
intestinal  obstruction. 


adhesions:  symptoms 


297 


In  the  insidious  form  the  symptoms  at  first  are  sh'ght  and  they  may 
appear  only  at  intervals.  The  patient  complains  of  soreness  in  the 
intestines  or  about  the  region  of  the  scar.  She  is  usually  constipated,  and 
finds  that  ordinary  cathartics  do  not  relieve,  and  sometimes,  after  a 
dietary  indiscretion,  the  bowels  will  be  completely  inactive  for  a  week  or 
so  and  then  move  again  with  fair  regularity.  She  is  apt  to  experience 
an  unusual  amount  of  pain  or  distress  with  the  menstrual  flow,  of  a 
griping  or  colicky  nature,  even  if  the  operation  has  not  involved  the 
pelvic  organs.  In  many  cases  the  patient  gets  more  or  less  accustomed 
to  her  new  state,  and  gradually,  in  the  course  of  time,  the  S3^mptom3 
wear  away  as  the  adhesions  attenuate  and  disappear.  Not  infrequently, 
however,  a  condition  of  neurasthenia  develops,  and  the  morbid  interest 
of  the  patient  in  her  own  symptoms  magnifies  them  until  she  becomes 
a  neurotic,  ill-nourished  invalid. 

In  contradistinction  to  these  effects  of  partial  obstruction  or  im- 
pairment of  function,  as  the  intestines  or  viscera  are  distorted  or  con- 
stricted by  the  pull  of  adhesions,  is  the  strangulation  which  sometimes 
occurs  from  the  constriction  of  a  loop  of  intestine  under  or  about  an 
adhesion  band.  Acute  obstruction  may  occur  at  any  time  from  a  few 
weeks  to  many  months  after  the  operation.  It  is  usually  preceded  by 
some  of  the  indefinite  symptoms  just  noted,  but  it  may  appear  out  of 
a  clear  sky — as,  for  instance,  in  a  patient  upon  whom  we  recently  oper- 
ated for  strangulation  of  the  gut  in  a  loop  of  omentum  t\velve  years  after 
the  uneventful  recovery  from  an  abdominal  operation. 

The  symptoms  are  those  of  acute  intestinal  obstruction  from  any 
cause.  They  depend  to  some  extent  upon  obstruction  of  the  current 
of  gas  and  feces,  but  probably  to  a  greater  degree  to  obstruction  of 
the  circulation.  Thus,  a  patient  with  obstruction  may  nevertheless 
continue  to  pass  small  quantities  of  semifluid  feces  and  gas.  The 
characteristic  symptoms  are  acute  pain,  more  or  less  generalized,  and 
tenderness,  at  first  directly  over  the  seat  of  the  trouble,  but  later  rather 
difiicult'  to  localize  on  account  of  spasm  of  the  abdominal  muscles; 
there  are  vomiting,  distention,  at  first  to  be  noted  just  above  the  seat  of 
the  constriction,  spasm,  which  is  ordinarily  less  marked  than  in  peri- 
tonitis, and  general  pallor  and  sweating.  The  first  enema  or  two  may 
bring  away  feces  if  the  bowel  below  the  point  of  obstruction  was  fairly 
full  before  the  strangulation  began,  or  if  the  lumen  of  the  intestine  is 
not  entirely  closed  off  at  the  point  of  constriction. 

Prophylaxis. — ^The  matter  of  prophylaxis  is  an  important  part 
of  abdominal  technique,  and  the  lines  which  are  to  be  followed  at  the 
time  of  operation  have  already  been  suggested.     The  English  sum  these 


298  POSTOPERATIVE   HERNIA:   ADHESIONS 

up  under  the  expressive  phrase,  "toilet  of  the  peritoneum."  They  may- 
be restated  categorically,  thus: 

Employ  aseptic  rather  than  antiseptic  technique,  avoid  the  use  of 
chemicals  for  any  purpose,  and  use  only  warm  normal  saline  for  flushing 
out. 

Operate  under  conditions  of  warmth  and  moisture  which  will  as 
closely  simulate  those  of  the  peritoneal  cavity  as  possible;  keep  all 
exposed  or  delivered  viscera  protected  by  gauze  pads  kept  warm  and 
moist  by  hot  saline  solution. 

Protect  such  parts  as  are  not  involved  in  the  operation  by  walling 
off  with  pads  of  moist  gauze. 

Allow  no  rough  retraction,  no  inconsiderate  handling  or  sponging 
of  the  intestine,  or  needless  or  ungentle  manipulation. 

Use  moist  or  hot  dry  strips  and  sponges  within  the  abdomen. 

Suture  the  peritoneum  carefully  and  avoid  the  use  of  the  cautery. 

Cover  the  ends  of  pedicles,  appendix,  and  hysterectomy  stumps  so 
far  as  practicable  by  sewing  the  peritoneum  together  over  them  in  such 
a  manner  as  to  leave  a  smooth  peritoneal  surface  behind. 

Leave  no  large  surfaces  denuded  of  peritoneum;  if  no  other  means 
of  relief  offers,  cover  in  by  means  of  an  omental  flap  or  graft. 

Remove  all  blood-clot;  if  oozing  is  anticipated  after  sewing  up, 
provide  for  its  stasis  or  outlet. 

Drain  only  when  necessary,  use  only  a  sufficient  amount  of  gauze 
to  serve  the  purpose,  and,  except  where  contact  with  peritoneum  is 
intended,  protect  it  by  rubber  tissue. 

After  the  Trendelenburg  posture,  rearrange  the  coils  of  intestine  in 
their  natural  positions. 

Before  sewing  up  draw  down  the  omentum  under  the  abdominal 
wall. 

Various  artificial  methods  have  been  experimented  with  as  means 
of  preventing  the  formation  of  postoperative  adhesions  in  the  abdomen, 
between  brain  and  dura,  and  about  tendons.  While  no  single  agent 
has  demonstrated  its  assured  fitness  for  this  purpose,  the  various  observa- 
tions are  worthy  of  record. 

The  painting  of  collodion  over  raw  surfaces  was  suggested  by  Stern;' 
this  method  is  no  longer  used. 

Miiller  originated  the  plan  of  leaving  the  abdomen  full  of  normal  saline 
solution;  Vogel  ^  declares  it  is  ineffectual.     E.  Marvel  ^  regards  a  solution 

^  Bruns'  Beitrage,  1889,  iv.  ^  Kent,  Zeit.  f.  Chir.,  Ixiii,  26. 

^  Jour.  Med.  Soc.  of  New  York,  Dec,  1905;  Jour.  Amer.  Med.  Assoc,  1907,  xlix,  986. 


adhesions:  prophylaxis  299 

of  adrenalin  in  normal  saline  as  of  value  by  preventing  plastic  exudate. 
The  use  of  silk  protective  has  been  advocated  by  C.  Lauenstein.^ 

Vogel  {op.  cit.)  claims  good  results  from  a  solution  of  gum  arable 
(gum  arabic,  i  part;  normal  saline,  2  parts;  filter  and  sterilize).  This 
is  injected  through  a  tube  just  before  the  wound  is  closed. 

The  use  of  thin  gold-beater's  skin,  made  from  the  peritoneum  of 
catde  (sold  in  America  under  the  name  of  Cargile  membrane),  has  been 
advocated  by  Duschinsky^  and  by  Charles  Cargile,  of  Bentonville, 
Arkansas.  Experiments  by  A.  B.  Craig  ^  and  A.  G.  Ellis  show  that  litde 
reliance  can  be  placed  on  this  method. 

The  injection  of  salts  of  physostigmin  have  been  recommended  to 
prevent  abdominal  adhesions  through  the  early  institution  of  peristalsis,* 

The  use  of  sterile  olive  oil  over  raw  surfaces  was  first  made  by  August 
Martin,  of  Berlin.^  Blake  concludes,  as  a  result  of  an  experience  with 
its  use  in  14  operations  on  animals  and  7  on  human  beings,  that  "oil, 
absolutely  sterile,  may  be  used  in  the  peritoneal  cavity  of  patients  in 
moderate  quantities,  i  to  4  drams,  without  danger,  general  or  local; 
that  it  remains  in  the  peritoneal  cavity  for  periods  of  from  five  to  fifteen 
days  and  possibly  even  longer;  that  its  presence  tends  to  prevent  early 
and  direct  adhesion  of  denuded  or  inflamed  peritoneal  surfaces,  and, 
therefore,  that  its  use,  under  the  above  precautions,  is  indicated  and  is 
moderately  effective  in  sometimes  preventing  and  usually  diminishing 
the  formation  of  postoperative  peritoneal  adhesions." 

In  contradiction  to  these  findings  stand  the  researches  of  M.  Busch  and 
E.  Bilergeil.^  They  have  experimented  with  clean  olive  oil,  solid  paraffin, 
anhydrous  lanolin,  liquid  paraffin,  gum  arabic,  agar,  gelatin,  fibrolysin, 
and  the  subcutaneous  injection  of  physostigmin,  and  -conclude  that  it 
is  impossible  to  prevent  contact  between  abraded  or  injured  surfaces  of 
peritoneum  and  the  consequent  production  of  adhesions  by  means  of 
mucilaginous  or  similar  substances  left  in  the  abdominal  cavity.  Some 
of  the  materials,  such  as  lanolin,  paraffin,  oil,  and  agar,  they  assert 
cause  irritation  of  the  peritoneum,  while  non- irritating  solutions,  such 
as  gum  arabic,  gelatin,  and  fibrolysin,  are  too  rapidly  absorbed  to  be 
of  any  mechanical  advantage.  They  recommend  careful  operating 
and  strict  observance  of  the  rules  of  peritoneal  toilet. 

M.  L.  Harris  ^  has  had  good  results  from  the  use  of  silver-foil  after 

^  Archiv  f.  klin.  Chir.,  1890,  xlv,  244.  ^  Inaug.-Dissert.,  Miinchen,  1898. 

^  Ann.  Surg.,  June,  1905,  xli,  801. 
*D.  H.  Craig,  Amer.  Jour.  Obst.,  1904,  xlix,  449. 

^  Ellis,  Proceed.  Path.  Soc.  of  Phila.,  1906,  ix,  and  J.  B.  Blake,  Surg.  Gyn.  and  Obst., 
1908,  vi,  667.  ®  Archiv  f.  klin.  Chir.,  1908,  Ixxxvii,  99. 

^  Jour.  Amer.  Med.  Assoc,  1904,  xlii,  763. 


300  POSTOPERATIVE   HERNIA:   ADHESIONS 

operations  on  the  brain,  and  Ellis  (op.  cit.)  has  demonstrated  the  value 
of  films  of  celloidin  wrapped  about  tendons  to  prevent  adhesion  to  their 
sheaths. 

Treatment. — The  non-operative  treatment  of  adhesions  consists 
in  the  early  and  consistent  use  of  gentle  laxatives  and  a  carefully  selected 
diet.  This  should  be  digestible  to  the  point  of  leaving  litde  residue, 
which  might  clog  the  narrowed  and  imperfectly  acting  gut.  It  should 
be  finely  di\ided  and  well  masticated.  Byford  ^  has  obtained  relief 
from  symptoms  through  active  exercise,  probably  through  the  stretching 
and  attenuation  of  the  adhesions  which  result.  He  cites  one  case  which 
was  permanently  cured  by  horseback  riding  on  a  roughly  gaited  horse. 
In  cases  where  this  is  not  practicable  or  advisable,  massage  and  elec- 
tricity may  be  applied  to  the  abdomen  with  advantage.  (See  Chaps. 
XXXVII  and  XXXVIII.) 

Operative  treatment  becomes  imperative  in  cases  where  non-operative 
methods  give  no  relief,  when  pain  and  spasm  become  severe,  or  when 
symptoms  of  acute  obstruction  appear.  In  the  ordinary  case  the  sur- 
geon should  not  wait  for  the  obstruction  to  become  absolute,  for  by 
this  time  beginning  necrosis  of  the  bowel  is  already  frequently  in  evi- 
dence and  resection  may  be  necessary. 

The  incision  should  be  made  nearly  over  the  obstruction,  if  this  can 
be  localized,  otherwise  in  the  median  line,  below  the  umbilicus.  Care 
should  be  taken  in  incising  the  peritoneum  lest  adherent  intestine  be 
punctured.  Recent  delicate  adhesions  may  be  separated  by  sponging; 
if  they  are  broad  enough  to  contain  vessels  of  size,  they  should  be  tied 
off.  Adhesions  a  year  or  more  old  usually  are  poorly  supplied  with 
vessels,  and,  if  not  too  large,  may  simply  be  divided  at  their  points  of 
origin  and  the  intermediate  portions  removed,  lest  a  long  end  left  free  in 
the  abdomen  contract  fresh  adhesion.  _  Broad  adhesions  leave  behind 
large  raw  areas  which  should  be  protected  in  any  suitable  fashion.  If 
the  intestine  is  kinked  by  a  band,  it  usually  straightens  out  as  soon  as 
the  band  is  divided.  If  it  is  obstructed  by  close  adhesion  to  the  parietal 
peritoneum,  it  is  best  to  cut  out  the  peritoneum  and  leave  it  attached 
to  the  bowel,  covering  over  the  raw  surface  left  behind  by  bringing  the 
peritoneal  edges  together.  This  plan  must  also  be  employed  as  far  as 
possible  in  case  the  intestine  is  matted  together.  Raw  surfaces  which 
cannot  be  protected  in  other  ways  should  be  covered  with  portions  of 
omentum.^ 

^  Surg.  Gyn.  and  Obst.,  1909,  v\\\,  576. 

^  F.  B.  Lund,  Remarks  on  Intestinal  Obstruction  by  Bands  Following  Operations  on  the 
Peritoneal  Cavity,  Boston  Med.  and  Surg.  Jour.,  1902,  cxlvi,  565;  J.  C.  Webster,  The  Pre- 
vention of  Adhesions  in  Abdominal  Surgery,  Surg.  Gyn.  and  Obst.,  1909,  \dii,  574. 


CHAPTER  XXXV 

ABDOMINAL  SWATHES:  THEIR  USE  AND  ABUSE 

It  has  until  recently  been  considered  the  proper  thing  to  recommend 
that  a  iitted  abdominal  swathe  be  worn  one  to  twelve  months  after  all 
abdominal  sections/  and  that  trusses  or  specially  adapted  swathes, 
containing  pressure  plates,  be  applied  after  ail  operations  for  hernia. 
The  practice  is  rapidly  becoming  more  and  more  restrrcted. 

If  an  abdominal  incision  is  made  with  proper  regard  for  anatomic 
mechanics,  and  is  closed  with  efficient  deliberation,  and  the  approxima- 
tion of  the  wound-edges  is  then  supported  by  strips  of  adhesive  plaster 
carefully  applied  and  maintained  during  the  plastic  period  of  healing 
— namely,  twenty-one  to  thirty  days — a  solid  and  resistant  scar  is  to  be 
expected.  With  median  line  incisions,  in  fat,  flabby-muscled  individuals, 
and  in  the  presence  of  sepsis,  further  support  may  be  necessary.  Other- 
wise, it  may  be  contended  that  an  abdominal  swathe  has  a  positively 
deleterious  effect  in  so  far  as  it  encourages  atrophy  of  abdominal  muscles 
through  disuse.  Abel  ^  shows  by  statistics  that  the  abdominal  swathe 
has  nothing  to  do  with  preventing  the  formation  of  hernia. 

The  arguments  advanced  by  those  who  favor  the  routine  application 
of  the  swathe  without  special  indication  are  varied.  They  hold  that 
the  presence  of  a  swathe  serves  to  remind  the  patient  of  the  fact  that  he 
has  a  weak  spot  in  his  abdominal  wall,  and  that  he  will  accordingly 
refrain  from  straining  himself  by  lifting  and  muscular  overexertion. 
The  swathe  is  said  to  guard  the  scar  against  the  extra  tension  resulting 
under  conditions  such  as  constipation  and  respiratory  affections,  and 
during  physical  effort.  Finally,  it  is  stated  that  the  public  has  become 
so  accustomed  to  the  idea  of  wearing  a  swathe  after  abdominal  operation 
that  any  surgeon  who  neglects  its  use  will  lay  himself  open  to  the  serious 
criticism  of  his  patients  in  case  postoperative  hernia  does  develop. 

Wounds  heal  by  the  process  of  scar-tissue  formation.  After  about 
ten  days  the  line  of  incision  sho.ws  under  the  microscope  as  young  vascu- 
lar connective  tissue.  In  the  course  of  weeks  and  months  this  red  scar 
tissue   grad-ually   contracts   and   loses    its   vascularity,    becomes    more 

^  Kummer  (Corres.  f.  Schweizer  Acrzte,  1901,  xxxix,  361)  insists  that  an  abdominal 
bandage  be  worn  for  three  months  after  a  celiotomy. 
^  Archiv  f.  Gyn.  u.  Chir.,  Ivi,  656. 

301 


302  ABDOMINAL   SWATHES 

fibrous  in  character,  and  changes  permanently  into  white  scar  tissue. 
Skin  and  peritoneum  proHferate  quickly  and  heal  rapidly  by  the  forma- 
tion of  new  similar  structures;  connective  tissue,  fat,  and  muscle 
repair  by  the  formation  of  connective  tissue  and  repair  more  slowly; 
fascia  and  tendons  repair  very  slowly  by  means  of  connective  tissue. 
Whenever  circumstances  allow,  it  is  theoretically  advisable  carefully  to 
approximate  homologous  structures,  so  that  scar  contraction  will  unite 
firmly  muscle  to  muscle  and  fascia  to  fascia,  restoring  in  this  way  to  a 
greater  extent  the  integrity  of  the  abdominal  wall.  Septic  wounds 
require  a  longer  time  for  healing  than  do  aseptic,  and  repair  by  the 
formation  of  much  larger  amounts  of  connective  tissue,  resulting  in 
larger  scars. 

Postoperative  swathes  were  devised  to  support  the  abdominal  wall 
until  the  firm  white  scar  was  fully  formed,  in  an  endeavor  to  prevent 
hernia  during  the  process  of  healing,  and  to  overcome  the  tendency 
to  the  formation  of  a  thin,  wide  scar.  It  must  be  borne  in  mind  that  a 
swathe  is  to  all  intents  and  purposes  a  splint,  and  a  splint  causes  atrophy 
of  the  muscles  it  supports  and  whose  activity  it  limits.  It  is  not  to  be 
denied  that  there  are  cases  which  are  benefited  by  swathes  and  are 
protected  from  the  occurrence  of  hernia,  but  the  indications  are  gradually 
becoming  more  limited,  and  the  ill  effects  are  safeguarded  by  suitable 
exercises  for  the  abdominal  muscles  to  preserve  their  tone  and  to  increase 
their  development.  The  majority  of  cases,  depending  on  the  character 
of  the  wound  and  on  the  muscular  development  of  the  individual,  do 
perfectly  well  without  a  swathe  and  almost  never  show  postoperative 
hernias. 

In  the  McBurney  or  muscle- splitting  incision  the  only  cutting  done 
is  in  going  through  the  skin  and  peritoneum;  the  muscles  and  fasciae 
are  torn  apart  in  the  direction  of  their  fibers.  The  result  is  that  the 
structures  fall  together  naturally,  requiring  but  few  sutures.  Such  a 
wound  needs  no  support;  as  soon  as  retraction  ceases,  each  layer  as- 
sumes almost  its  former  integrity,  and  so  buttresses  every  other  layer 
against  strain  that  the  patient  may  be  allowed  up  in  three  days,  or  even 
earlier  in  a  small  wound,  without  support  or  risk,  provided  that  adhesive 
plaster  strips  are  used. 

The  right  rectus  incision,  while  not  perfect  mechanically,  is  well 
designed  in  that  it  brings  the  center  of  the  injured  rectus  muscle  over 
the  wound  in  the  deeper  layers  and  supports  it  against  strain.  A  patient 
with  such  an  incision  does  perfectly  well  without  a  swathe.  Occasion- 
ally herniae  are  reported  after  these  two  incisions,  but  investigation 
practically  always  reveals  the  fact  that  the  blame  can  be  placed  on  sepsis. 


THEIR    USE    AND    ABUSE  303 

too  long  an  incision,  or  unpractised  technique.  Incisions  above  the 
level  of  the  umbilicus  are  subject  to  no  great  amount  of  intra-abdominal 
pressure,  and  if  properly  closed,  practically  never  require  support. 

Incisions  in  the  median  line,  where  there  are  no  muscle-fibers,  heal 
slowly  and  entirely  by  connective  tissue.  It  is  safer  to  insist  that  such 
cases,  particularly  if  drained,  wear  a  swathe  and  take  supplementary 
exercises  for  about  six  months.  By  that  time  the  scar  is  as  firm  as  it  will 
ever  be,  and  the  further  support  of  a  swathe  is  useless  and  even  detri- 
mental. A  case  has  recently  come  to  my  notice  of  a  young  woman  who 
is  wearing  a  swathe  six  years  after  operation,  simply  because  she  has 
never  been  told  she  could  go  without  it. 

Abdominal  wounds  which  have  been  drained,  or  allowed  for  sepsis 
or  some  other  reason  to  heal  by  granulation,  should  be  supported  by 
swathes  for  six  months.  Advocates  of  the  McBurney  technique  declare 
that  this  is  usually  unnecessary  in  their  muscle-splitting  incision.  I  so 
believe.  However,  it  must  be  borne  in  mind  that  in  a  McBurney  inci- 
sion which  has  been  drained  for  any  length  of  time,  say,  forty-eight  hours 
or  over,  the  different  layers  fail  to  fall  together  into  close  approximation, 
and  the  intervening  space  has  to  fill  in  with  granulation  tissue.  In  the 
case  of  abdominal  wounds  which,  by  reason  of  emergency,  have  had 
to  be  sewed  up  by  through-and-through  sutures,  or  left  widely  open  for 
a  time,  fitted  swathes  should  be  worn  until  the  surgeon  is  satisfied  that 
the  scar  will  not  give  way.  For  this  class  of  cases  it  is  far  better  to  wear 
the  swathe  a  lifetime  if  the  patient  is  one  who,  should  hernia  appear, 
would  not  be  willing  or  in  condition  to  have  it  treated  surgically. 

In  addition  to  the  character  of  the  wound  we  must  give  consideration 
also  to  the  physical  development  of  the  individual.  Just  because  a 
patient  is  fat  is  not  a  sufficient  reason  for  applying  a  swathe.  Under 
the  fat  there  may  be  good  firm  muscles  capable  in  themselves  of  pre- 
venting hernia.  Fat  patients  generally  are  inclined  to  have  flabby 
muscles,  strained  by  the  large  accumulation  of  intraperitoneal  fat.  Such 
cases  demand,  first  of  all,  exercises  for  those  muscles,  and  the  exercises 
will  also  tend  to  diminish  the  fat;  a  swathe  may  often  be  worn  with  ad- 
vantage during  this  process.  Moreover,  in  a  fat  person  a  swathe  im- 
parts a  sense  of  security  and  satisfaction  that  will  give  confidence  to 
undertake  and  continue  exercise.  In  a  man  whose  abdomen  is  ap- 
proximately the  size  of  his  chest  at  expiration,  or  smaller,  a  swathe  is 
hardly  ever  to  be  considered  necessary. 

Women  ordinarily  stand  more  in  need  of  abdominal  support  than 
men  during  wound  healing,  on  account  of  their  naturally  less  muscular 
development,  decreased  still  further,  frequently,  by  the  wearing  of  corsets 


304  ABDOMINAL   SWATHES 

and  by  repeated  pregnancies.  In  a  well-developed  women  with  small 
abdomen  who  has  not  worn  corsets  no  swathe  is  necessary  under  ordinary 
circumstances.  In  a  woman  used  to  wearing  corsets  no  swathe  can 
serve  so  well  as  the  present-day  straight-front  corset.  The  corset  should 
be  advised,  if  support  is  necessary,  as  soon  as  the  tenderness  of  the 
scar  will  permit  its  being  worn.  In  a  woman  with  pendulous,  flabby 
abdomen  a  fitted  swathe,  with  perineal  straps,  or  a  specially  made  corset, 
may  be  prepared  for  the  purpose  of  relieving  the  scar  of  strain  and  the 
weight  of  the  abdominal  contents.  Cases  operated  on  for  malignant 
disease  which  show  any  signs  of  cachexia  should  wear  swathes  in  order 
to  support  their  weakened  muscles.  Cases  undergoing  an  operation 
which  m^aterially  reduces  the  intraperitoneal  contents,  either  by  the 
removal  of  the  fluid,  cysts,  or  masses  of  omentum,  should  wear  swathes 
until  the  abdominal  walls  have  readjusted  themselves.  Any  case  sub- 
ject to  chronic  cough  of  any  nature,  and  the  old  or  feeble,  should  wear  a 
swathe. 

The  question  of  swathes  following  hernia  operations  is  worthy  of 
special  consideration.  Many  varieties  of  swathes  have  been  devised 
for  use  after  operations  for  inguinal  and  femoral  hernia.  In  order  to 
relieve  tension  on  such  wounds  the  thigh  must  be  kept  flexed  on  the 
body,  slightly  adducted,  and  inverted.  No  swathe  yet  devised  will 
do  this  \yith  any  degree  of  comfort  to  the  patient.  The  patient  should 
be  kept  in  bed  until  satisfied  that  the  scar  is  firm,  usually  about  three 
weeks,  and  then  he  should  be  allowed  to  get  up,  with  instructions  not 
to  bend  backward  or  to  the  well  side  and  not  to  straddle.  In  this  way 
he  will  avoid  nearly  all  undesirable  strains.  As  epigastric  and  umbilical 
herniae  nearly  always  occur  in  fat  people,  and  the  operative  scar  is 
necessarily  in  the  median  line,  such  cases  should  wear  swathes.  Opera- 
tions for  ventral  and  postoperative  hernias  should  be  followed  by  the  use 
of  swathes. 

The  matter  of  the  type  of  swathe  to  employ,  when  one  is  decided 
upon,  is  not  to  be  settled  off-hand.  Like  most  apparatus  designed  as 
a  substitute  for  or  to  reinforce  normal  physical  function,  the  swathe  is 
a  makeshift.  Many  forms  have  been  designed,  sufiiciently  complicated 
to  suit  the  most  ingenious  mind,  and  depending  in  principle  on  minor 
details  usually  of  no  great  value.  These  are  marketed  under  various 
names.  It  must,  however,  be  understood  first  of  all  that  no  one  type 
of  swathe,  whether  or  not  it  represents  the  copyright  hobbies  of  some 
enthusiast,  will  do  for  every  case.  The  surgeon  should  have  clearly 
in  mind  what  purpose  he  expects  the  swathe  to  serve.  Most  hospitals 
have  relations  with  a  clever  woman  who  is  adept  in  designing  and  fitting 


THEIR   USE   AND    ABUSE 


305 


swathes  in  accordance  with  the  instructions  of  the  surgeons.     In  special 
cases,  at  least,  swathes  should  be  specially  fitted. 

Ordinarily,  simple  and  inexpensive  swathes  of  the  types  pictured 
(Figs.   96,  97,  98)   may  be  purchased  which  will  serve  every  purpose. 


Fig.  96. — Swathe. 
Showing  elastic  webbing  straps,  buckling  in  front,  and  designed  to  exert  an  upward  pull  on  lower  abdomen 

(Kny-Scheerer). 


Fig.  97. — Side  View  of  Swathe. 
Similar  to  that  iu  Fig.  96,  with  front  lacing  (Kny-Scheerer). 


Fig.  g8. — Swathe  of  Linen  Mesh,  Porous,  and  Containing  no  Elastic  (J.  Ellwood  Lee). 


The  less  the  complications  and  the  fewer  the  straps  and  buckles,  other 
things  being  equal,  the  better.     A  swathe  should  be  washable,  and  if  it 
contains  no  or  little  elastic  webbing,  so  much  the  better.    It  should  sup- 
20 


3o6  ABDOMINAL   SWATHES 

port  and  not  constrain  the  abdomen,  by  exerting  a  constant  lift  on  the 
suprapubic  bulge.  If  the  swathe  is  likely  to  slip  up,  it  should  be  held 
down  by  perineal  straps  or  leg-binders. 

When  the  swathe  is  applied,  the  patient  should  be  clearly  informed 
as  to  how  long  it  is  expected  that  its  use  will  be  necessary.  He  should 
understand  also  the  dangers  of  swathe  wearing,  for  nothing  encourages 
inguinal  hernia  more  than  body  movements  with  a  swathe  improperly 
applied,  for  instance,  tight  about  the  waist  and  loose  below.  A  swathe 
which  constricts  the  abdomen  but  does  not  support  it  will  do  far  more 
harm  than  good.  The  use  of  exercises  has  already  been  dwelt  upon. 
The  surgeon  should  see  the  patient  at  intervals  to  satisfy  himself  that 
the  swathe  is  properly  worn  and  the  directions  carried  out. 


CHAPTER  XXXVI 

ARTIRQAL  LIMBS;  POSTOPERATIVE  FLAT-FOOT 

ARTIFICIAL  LIMBS 

In  the  operative  treatment  of  wounds  the  surgeon  is  ordinarily 
actuated  by  the  principle  that  all  viable  tissue  should  be  saved.  The 
only  exception  to  this  principle  should  be  in  cases  involving  amputation 
of  limbs.  Due  consideration  must  be  given  to  the  important  matter 
of  efficient  prosthesis.  It  is  true  oftentimes,  for  example,  that  saving 
too  long  a  tibial  stump  means  inconvenience  and  discomfort  when  the 
patient  is  ready  later  to  wear  an  artificial  leg.  It  is  important,  therefore, 
in  performing  amputations  to  be  governed  by  the  experience  of  those 
who  have  to  do  with  the  making  and  fitting  of  artificial  limbs. 

Amputations  through  the  tarsus,  such  as  the  Chopart  and  Faraboeuf, 
are  usually  not  highly  satisfactory.  The  tarsal  bones  which  remain 
are  liable  to  be  pulled  out  of  place,  and  oftentimes  the  heel  is  so  retracted 
by  contraction  of  the  tendo  Achillis  that  the  scarred  surface  is  drawn 
under  the  leg  in  such  fashion  that  it  becomes  the  bearing  point  of  weight. 
On  account  of  its  unevenness  it  is  usually  intolerant  of  pressure.  This 
retraction  also  so  lengthens  the  leg  that  a  compensatory  elevation  of  the 
sole  of  the  shoe  on  the  other  foot  must  be  employed.  The  only  efficient 
artificial  limb  for  this  sort  of  amputation  is  one  having  a  leg,  the  front 
half  of  which  is  made  of  aluminum,  and  the  rear  half,  which  encloses 
the  calf  and  the  aluminum  shell,  of  leather.  As  an  ankle  articulation 
would  be  cumbersome,  it  is  better  to  have  instead  a  stiff  ankle  and  a  sole 
made  of  rubber.  This  appliance  should  be  so  fitted  that  the  weight 
of  the  body  is  borne  by  the  calf  of  the  leg,  not  by  the  end  of  the  stump. 

Amputations  about  the  ankle-joint,  the  Syme's  and  the  Pirogoff,  which 
have  flaps  formed  of  the  resistant  tissues  of  the  heel,  usually  provide 
stumps  which,  though  clumsy,  are  capable  of  weight-bearing.  If, 
however,  the  cicatrix  extends  over  the  bearing  point,  or  if  the  stumps 
are  tender,  they  do  not  allow -of  end-bearing,  and  legs  must  be  planned 
which  allow  of  no  pressure  on  the  extremity  but  distribute  the  weight 
over  the  lower  leg.  The  leg  ordinarily  applied  is  one  similar  to  that 
already  described.  If  fitted  with  a  mechanical  ankle-joint,  it  is  usually 
cumbersome  and  uncomfortable. 

307 


308  ARTIFICIAL    LIMBS;    POSTOPERATIVE    FLAT-FOOT 

The  amputation  of  choice,  where  amputation  is  necessary  betw^een 
the  metatarsals  and  the  knee,  is  the  amputation  of  both  hones,  which  gives 
a  stump  from  6  to  8  in.  long.  Generally  speaking,  in  operations  above 
the  ankle  the  longer  the  tibial  stump,  the  better,  but  stumps  which  reach 
close  to  the  ankle  are  usually,  in  the  majority  of  cases,  not  capable 
of  bearing  pressure,  because  the  flaps  are  poorly  nourished  and  are, 
therefore,  slow  in  healing,  and  are  extremely  liable  to  ulceration  if  sub- 
jected to  pressure.  This  is  due  partly  to  poor  collateral  circulation  in 
the  lower  third  of  the  leg  and  partly  to  the  absence  of  muscle  in  the 
flap.  Ulceration  frequently  necessitates  reamputation.  Moreover,  these 
stumps  are  usually  hypersensitive.  Long  tibial  stumps  are  likely  to  be 
enlarged  or  bulbous  at  the  tip,  w^hich  interferes  with  the  use  of  a  socket. 

Tibial  amputations  short  of  4  inches  are  of  practically  no  use  in  throw- 
ing the  lower  leg  forw^ard  in  walking.  In  addition,  they  are  likely  to  be- 
come atrophied.  The  fibula,  which  is  practically  subcutaneous,  as  a  result 
of  friction,  may  be  excited  to  periostitis,  and  sometimes  reamputation 
above  the  knee  is  the  only  relief  from  the  soreness  or  infection.  Ampu- 
tations, therefore,  in  the  middle  third  of  the  leg  are  the  most  likely  to  give 
good  results,  both  from  the  point  of  view  of  the  surgeon  and  the  maker 
of  limbs. 

The  legs  which  are  suitable  for  these  amputations  consist  of  a  lower 
leg  or  socket  made  of  willow  covered  with  parchment,  a  foot  made  of 
willow,  felt,  or  rubber,  with  or  without  an  ankle-joint,  and  a  thigh  socket 
made  of  leather,  to  lace  about  the  thigh  and  connect  with  the  lower  leg 
by  means  of  hinged  side  irons.  Not  infrequently  in  cases  of  tibial 
amputations  the  knee-joint  becomes  contracted,  either  as  a  result  of  the 
primary  injury  or  from  neglect  in  exercising  the  leg  during  the  period 
after  the  stump  has  healed  and  before  the  leg  is  finally  applied.  If  a 
stump  becomes  contracted  at  right  angles  so  that  it  cannot  be  fully 
extended,  or  in  case  a  stump  is  so  short  that  it  is  of  no  value  in  flexing 
the  knee-joint  of  an  artificial  leg,  it  is  allowed  to  remain  contracted, 
and  the  stump  then  becomes  a  knee-bearing  stump,  and  a  leg  is  con- 
structed so  as  to  receive  the  knee  in  the  flexed  position.  This  appliance 
is  unsightly  and  complicated.  Ordinarily,  a  stump  of  proper  length 
can  be  brought  to  full  extension  either  by  manipulation  or  by  the  use 
of  an  artificial  leg  which  has  been  properly  adapted.  This  may  be 
accomplished  by  applying  a  leg  which  is  fitted  with  a  lacing  attachment 
that  passes  over  the  rear  of  the  stump  in  such  a  way  as  to  exert  constant 
pressure.  This  appliance  tends  to  stretch  the  contracted  hamstrings 
progressively  until  at  last  it  can  be  removed  and  the  ordinary  socket 
worn. 


ARTIFICIAL   LIMBS  309 

The  following  letter  is  from  a  patient  whose  leg  I  amputated  at  the  point 
of  election.  It  is  given  entire,  because  it  presents  the  subjective  attitude  of 
one  artifiicial-leg  wearer.  The  writer  is  a  man  of  keen  inteUigence  and 
good  mechanical  ability: 

"Dear  Dr.  Crandon: 

"In  regard  to  the  artificial  leg  business,  it  has  been  my  experience  that 
the  different  manufacturers  all  have  a  story  to  tell  trying  to  convince  one  that 
theirs  is  the  only  real  thing.  All  these  patent  ankles  and  different  appliances 
simply  give  them  something  to  talk  about. 

"The  first  Umb  I  had  was  what  they  call  a  sUp-socket,  which  was  made  of 
leather.  It  is  a  very  heavy,  cumbersome  leg,  and  the  slip-socket  I  do  not  con- 
sider of  any  benefit.  The  only  thing  for  me  to  do  is  to  select  a  good,  honest, 
painstaking  leg  manufacturer  and  one  who  has  patience  to  see  that  you  are 
suited.  I  consider  a  wooden  leg  the  most  satisfactory,  inasmuch  as  it  is  lighter 
and  not  so  cumbersome,  being  smaller  in  circumference  and  will  hold  its  shape 
much  better  than  any  leather  preparation  which,  as  you  will  readily  see, 
will  change  if  it  is  subjected  to  moisture  and  then  heat,  which  they  all  are. 

' '  I  suppose  any  artificial  Umb  would  be  a  disappointment  to  a  person  at 
first,  but  after  one  gets  accustomed  to  wearing  it,  they  soon  find  out  that  it  is 
not  altogether  in  the  limb,  but  rather  the  unnatural  feeUng  which  a  person 
has,  and  of  course,  the  stump  being  tender,  there  is  nothing  made  that  a  per- 
son can  put  on  and  wear  without  more  or  less  inconvenience  at  first. 

"  I  am  getting  along  first  rate,  and  as  I  look  back  I  think  that  I  have  done 
as  well,  if  not  better,  than  can  be  expected.  I  have  been  able  to  drive  my  own 
car  all  summer  without  any  inconvenience — in  fact,  have  just  returned  from  a 
trip  through  the  White  Mountains. 

' '  In  regard  to  circulars  or  catalogues,  I  should  read  them  all  critically  and 
be  slow  to  decide." 

Amputation  through  the  knee-joint  may  give  a  useful  stump  if 
properly  performed.  In  order  to  bear  weight  the  flap  should  be  thick 
and  the  scar  high  up  and  out  of  the  way.  The  condyles  should  not  be 
scrap'ed  or  otherwise  disturbed,  and  the  patella  should  be  either  removed 
or  else  firmly  fixed  in  the  depression  between  the  condyles.  Such  a 
stump  will  have  a  nodular  end  and  may  be  clumsy  in  appearance, 
but  it  will  usually  be  capable  of  end-bearing  without  sensitiveness  or 
pain. 

In  amputations  of  the  thigh  the  same  principles  should  govern  the 
operator  as  in  the  case  of  tibial  amputation.  Thigh  stumps,  like  those 
of  the  tibia,  are  not  capable  of  bearing  w^eight  upon  their  extremities, 
as  a  rule,  and,  therefore,  reliance  must  be  placed  upon  the  socket. 
Amputations  which  are  too  close  to  the  knee  do  not  allow  sufficient 


3IO  ARTIFICIAL   limbs;    POSTOPERATIVE   FLAT-FOOT 

room  for  the  mechanical  knee-joint  with  which  these  legs  are  supplied. 
For  this  reason  it  is  found  that  the  most  suitable  point  for  amputation 
is  at  the  junction  of  the  middle  and  lower  thirds.  Thigh  amputations 
which  leave  a  bony  stump  short  of  5  in.  in  length  usually  are  inadequate 
from  a  functional  point  of  view,  on  account  of  insufficient  lever- 
age. For  this  reason,  in  cases  of  amputation  above  the  point  of  elec- 
tion the  perfection  of  the  flap  should  be  sacrificed  to  the  length  of  the 
bone. 

Thigh  stumps,  like  those  below  the  knee,  are  subject  to  contraction, 
provided  the  use  of  an  artificial  leg  is  too  long  postponed.  This  con- 
traction is,  however,  usually  overcome  with  slight  difficulty  after  the  leg 
is  applied.  The  legs  are  made  like  those  already  described  for  tibial 
stumps,  except  that  the  socket  is  fitted  to  the  thigh  and  the  knee  is 
supplied  with  a  spring  which  allows  of  flexion  in  walking  so  as  to 
simulate  the  natural  gait.  An  appliance  is  fitted  to  the  knee,  which 
holds  it  in  the  flexed  position  when  the  wearer  is  sitting.  The 
socket  is  held  on  by  a  band  of  webbing  which  goes  on  over  the  oppo- 
site shoulder. 

After  amputation  through  the  hip,  legs  are  supphed  similar  to  those 
just  described,  with  a  few  modifications.  The  socket  is  wide  and  shallow, 
and  has  a  broad,  rounded  edge,  so  that  the  wearer  is  practically  sitting 
upon  it.     It  is  held  in  place  by  a  broad  belt  and  suspender. 

In  all  amputations  in  general  there  are  details  which  should  never 
be  overlooked.  Of  these,  the  most  important  is  the  position  of  the  scar. 
If  the  stump  is  to  be  end-bearing,  that  is  to  say,  if  the  extremity,  as  in 
the  case  of  the  amputation  at  the  ankle-  or  knee-joint,  is  to  take  the 
weight  of  the  leg,  the  scar  should  be  out  of  the  way  in  front  or  behind. 
If  the  stump  is  to  be  a  conical  one,  as  in  the  case  of  amputations  of  the 
tibia  and  thigh,  the  scar  should  be  so  placed  near  the  extremity  that  it 
will  not  be  subjected  to  pressure  or  irritation  from  the  socket.  The 
presence  of  sharp  edges  or  spicules  of  bone  or  corners  which  are  not 
rounded  off  will  make  themselves  disagreeably  felt  after  the  stump 
has  atrophied  with  use.  The  slightest  pressure  will  cause  irritation 
of  the  skin  over  such  points  and  usually  leads  to  ulceration,  which  does 
not  heal  up  permanently  until  the  bone  is  properly  trimmed.  Nerves 
should  always  be  dra^^  n  down  and  cut  off  short,  so  that  they  will  retract 
into  the  tissues.  If  they  are  caught  in  the  scar,  they  will  give  rise  to 
amputation  neuralgia  or  other  serious  symptoms.  Sometimes  the  cut 
ends  will  proliferate  and  form  neuromata,  which  are  accompanied  by 
hallucinations  of  sensation  in  the  absent  limb,  usually  necessitating  re- 
amputation. 


ARTIFICIAL   LIMBS  31I 

The  flap  should  be  so  well  planned  that  it  will  be  well  nourished. 
It  should  contain  tissue  enough  to  amply  protect  the  bony  stump,  but 
the  tissue  need  not  be  thick,  because  it  must  shrink  to  its  maximum 
before  the  socket  can  be  worn  to  the  best  advantage.  It  is  best  to  have 
this  shrinkage  accomplished  and  the  desired  conical  shape  attained 
before  the  leg  is  fitted,  as  this  will  save  the  trouble  and  expense  of  suc- 
cessive refittings  of  the  leg-socket  as  the  stump  shrinks  in  use. 

This  shrinkage  may  be  accomplished  by  keeping  the  stump  tightly 
bandaged  from  the  time  the  skin  is  healed.  The  bandage  may  ad- 
vantageously be  made  of  cotton  flannel,  and  it  should  be  applied  in  case 
of  a  tibial  stump  from  the  tip  to  the  knee,  and  in  case  of  a  thigh  amputa- 
tion from  this  extremity  to  the  body.  Unless  this  is  carried  out,  the 
stump  will  be  soft  and  flabby.  If  it  is  properly  attended  to,  the  stump 
will  become  tough,  solid,  and  resistant,  and  will  gradually  diminish  in 
size. 

Instead  of  the  bandage,  we  can  make  use  of  a  leather  appliance  called 
a  stump-corset.  This  is  molded  to  fit  the  stump,  and  is  made  to  lace 
up  so  that  graduated  pressure  can  be  applied  and  the  desired  end  at- 
tained. Ordinarily,  under  this  treatment  the  patient  is  ready  to  be 
measured  for  his  leg  within  a  fortnight  after  the  wound  has  healed,  so 
that  he  can  be  up  and  about  on  crutches.  To  prevent  contractions  the 
stump  should  be  exercised  and  given  proper  massage  and  manipulation 
until  the  limb  is  ready.  If  the  stump  undergoes  further  shrinkage  in 
the  socket,  a  new  socket  may  be  supplied,  or,  if  the  shrinkage  is  slight, 
it  can  be  compensated  by  wearing  thicker  socks. 

Artificial  hands  may  be  fitted  to  a  forearm  which  is  amputated  at 
or  above  the  wrist,  or,  if  part  of  the  hand  remains,  artificial  fingers  can 
be  supplied.  For  amputation  at  the  middle  of  the  forearm  an  appliance 
may  be  fitted  which  will  allow  of  motion  at  the  elbow.  It  is  held  in 
place  by  a  broad  strap,  encircling  the  arm  above  the  elbow.  The 
thumb  of  the  artificial  hand  may  be  made  to  grasp  by  means  of  a  cord 
which  goes  over  to  the  opposite  shoulder. 

In  amputations  above  the  elbow  the  socket  is  made  so  as  to  go  over 
the  shoulder,  and  it  is  held  in  place  by  a  strap  about  the  body.  Cords 
may  be  fitted  to  control  motion  at  the  elbow  and  thumb.  Stumps  on 
the  upper  extremity  are  not -required  to  bear  weight,  but  insomuch  as 
friction  from  the  socket  comes  upon  the  sides  of  the  stump,  it  is  advisable 
to  have  the  scar  at  the  extremity. 


312  ARTIFICIAL   LIMBS;    POSTOPERATIVE    FLAT-FOOT 

POSTOPERATIVE   FLAT-FOOT 

After  a  severe  operation  or  in  a  patient  for  any  reason  much  debili- 
tated, on  putting  the  feet  first  down  to  the  floor  and  attempting  to  walk, 
the  feet,  ankles,  and  legs  are  liable  to  swell.  Cold  spraying,  massage, 
and  flannel  bandages  will  help  to  make  this  stage  pass  quickly. 

Many  patients  after  a  severe  surgical  experience,  especially  if  the 
stay  in  bed  has  been  long,  will  rise  at  first  with  their  muscles  and 
ligaments  so  atrophied  that  symptoms  of  a  weak  or  "  flat  "  foot  will 
immediately  appear.  This  is  especially  seen  after  fractures,  partic- 
ularly if  the  foot  has  not  been  held  at  right  angles  to  the  leg  and  well 
adducted. 

This  condition  of  muscle  atrophy,  through  disuse  or  improper  use, 
is  indeed  the  common  etiology  of  so-called  flat  feet,  and  for  it  the  fol- 
lowing exercises  are  recommended: 

I.  Stand  stiff-kneed,  the  feet  3  or  4  inches  apart,  parallel  or  slightly  toeing 
in,  the  toes  making  a  grasping  effort.  This  is  the  correct  standing  posture 
(Fig.  99)- 


Fig.  99. 

II.  Standing  with  knees  "broken"  or  slightly  bent  forward,  the  knee- 
caps turned  outward  to  simulate  bow-legs,  the  feet  as  before,  parallel  or 
slightly  toeing  in,  the  toes  grasping.  This  is  a  position  such  as  the  gorilla 
or  the  ourang  takes.  It  is  a  perfectly  stable,  strong  posture.  The  weight  of 
the  body  as  the  next  step  is  taken  in  this  position  is  not  thrown  suddenly  and 


POSTOPERATIVE    FLAT-FOOT 


3'^3 


wholly  on  the  arches  of  the  feet,  but  the  load  is  taken  up  and  distributed  in 
the  spring  action  of  knees,  ankles,  and  feet  (Fig.  loo). 


Fig.  loo. 


III.  The  legs  are  crossed,  the  feet  placed  parallel,  2  inches  apart,  the 
weight  equally  divided  between  the  feet.     This  posture,  maintained  one 


Fig.  loi. 


minute  and  then  reversed,  brings  into  play  all  the  muscles  of  balance  (Fig. 
101). 


314 


ARTIFICIAL   limbs;    POSTOPERATIVE    FLAT-FOOT 


IV.  Stand  on  one  foot  placed  straight  forward,  the  other  foot  curled 
around  behind  the  standing  angle.  Balance  in  this  position  without  other 
support  for  a  minute,  first  on  one  foot,  then  on  the  other  (Fig.  102). 


Fig.  102. 


These  exercises  barefooted,  or  in  correct  shoes,  should  be  taken  for  two 
or  three  minutes,  five  to  twenty  times  a  day;   in  other  words,  whenever  the 


Fig.  103. — Weak,  Out-toeing  Posture,  Called  "  Lady-like." 

opportunity  presents  for  a  moment,  until  the  springy,  balancing  posture  and 
gait  of  childhood  are  recovered. 


POSTOPERATIVE   FLAT-FOOT 


315 


The  shoe,  to  allow  for  this  correct  standing  and  walking,  must  have  the 
following  characteristics  (Fig.  104) : 

It  should  be  light  in  weight,  soft  and  flexible  in  shank  and  all  other  parts, 
and  the  low,  flat  heel  should  be  rendered  balancing  and  unstable,  best  by  the 
use  of  soft  rubber,  either  for  the  whole  heel  or  for  the  outer  front  corner.  The 
construction  should  be  such  that  in  size  and  shape  the  shoe  shall  not  pinch 
the  extended  foot,  bearing  all  the  weight  of  the  body,  and  the  inner  sole  so 
made  that  the  foot  shall  not,  after  a  short  time,  sink  down  in  the  middle  of 


Fig.   104. — Good  Shoeing. 
Oxford,  thin  leather,  unstable  heel,  flexible  shank,  "  foot-shaped"  last. 

the  plantar  region  as  into  a  trough.  The  upper  should  be  high  enough  in  front 
to  allow  the  freest  toe-flexion,  and  over  the  middle  of  the  foot,  to  let  the  dorsum 
of  the  foot  raise  itself  as  the  toes  grasp  the  sole.  The  counter  should  be  low, 
to  allow  free  motion  at  ankle.  There  should  be  no  "fit"  in  the  usual  sense 
of  the  word,  but  yet  enough  fitness  for  the  particular  foot  for  a  loose  lacing 
to  prevent  slipping  at  the  heel. 

The  shoe  should  always  be  an  Oxford,  allowing  for  freest  play  of  the  ankle- 
joint.  It  is  no  more  reasonable  to  bind  a  high  shoe  around  the  ankle  than  to 
put  a  leather  support  on  the  knee. 


CHAPTER  XXXVII 

FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVE- 
MENTS 

The  definition  and  manner  of  doing  massage  ^  are  not  rendered  any 
dearer  by  calling  slow  and  gentle  stroking  in  a  centripetal  direction 
effleurage,  or  by  speaking  of  deep  rubbing  as  massage  a  friction,  or  by 
using  the  term  petrissage  for  deep  manipulation  ^Yithout  friction,  or  by 
calling  percussion  tapotement,  but,  custom  having  sanctioned  the  use 
of  these  words,  it  becomes  necessary  to  mention  them. 

The  multiform  subdivisions  under  which  the  various  procedures 
,of  massage  have  been  described  can  all  be  grouped  under  four  heads — ■ 
namely,  friction,  percussion,  pressure,  and  movement.  Malaxation, 
manipulation,  deep  rubbing,  kneading,  or  massage,  properly  so  called, 
is  to  be  considered  as  a  combination  of  the  last  t^vo.  Each  and  all  of 
these  may  be  gentle,  moderate,  or  vigorous,  according  to  the  require- 
ments of  the  case  and  the  physical  qualities  of  the  manipulators.  Some 
general  remarks  here  will  save  repetition:  (i)  All  the  single  or  com- 
bined procedures  should  be  begun  moderately,  gradually  increased  in 
force  and  frequency  to  the  fullest  extent  desirable,  and  should  end 
gradually  as  begun.  (2)  The  greatest  extent  of  surface  of  the  fingers 
and  hands  of  the  operator  consistent  with  ease  and  efiicacy  of  movement 
should  be  adapted  to  the  surface  worked  upon,  in  order  that  no  time  be 
lost  by  working  with  the  ends  of  the  fingers  or  one  portion  of  the  hands 
when  all  the  rest  might  be  occupied.  (3)  If  too  near  the  patient,  the 
manipulator  will  be  cramped  in  his  movements;  if  too  far  away,  they 
will  be  indefinite,  superficial,  and  lacking  in  energy.  (4)  The  patient 
should  be  placed  in  an  easy  and  comfortable  position,  with  joints  midway 
between  flexion  and  extension,  in  a  well-ventilated  room,  at  a  tempera- 
ture of  70°  to  75°  F.  Any  sensations  of  tickling  will  soon  be  overcome 
by  the  effects  of  the  massage  if  ordinary  tact  be  used.  (5)  What  con- 
stitutes the  dose  of  massage  is  to  be  determined  by  the  force  and  fre- 
quency of  the  manipulations  and  the  length  of  time  during  which 
they  are   employed,  considered  with   regard  to  their  effect  upon  the 

^  This  entire  chapter  is  quoted  from  "A  Treatise  on  Massage"  by  Dr.  Douglass 
Graham,  of  Boston  (Phila.  and  London,  J.  B.  Lippincott  Co.,  IQ02),  with  Dr.  Graham's 
ven,^  kind  permission  and  approval  and  through  the  courtesy  of  the  pubHshers. 
316 


FRICTION  317 

patient.  A  good  manipulator  will  accomplish  more  in  fifteen  minutes 
than  a  poor  one  will  in  an  hour,  as  an  old  mechanic  working  deliberately 
will  accomplish  more  than  an  inexperienced  one  working  furiously. 
(6)  The  direction  of  the  procedures  should  almost  invar 'ably  be  from 
the  extremities  to  the  trunk,  from  the  insertion  to  the  origin  of  the 
muscles,  in  the  direction  of  the  returning  currents  of  circulation. 

FRICTION 

Friction,  or  effleurage,  may  be  spoken  of  as  circular  and  rectilinear; 
the  latter  may  be  vertical  or  parallel  to  the  long  axis  of  a  limb,  or  horizontal 
transverse,  or  at  right  angles  to  the  long  axis.  Transverse  friction  is 
a  very  ungraceful  and  awkward  procedure.  It  has  been  introduced  on 
theoretic  considerations  alone,  and  may  without  loss  be  laid  aside.  A 
slight  deviation  from  the  method  ordinarily  recommended  in  doing 
straight-line  friction  I  have  found  to  be  more  advantageous,  for,  though 
in  almost  every  case  the  upward  strokes  of  the  friction  should  be  the 
stronger,  so  as  to  aid  the  venous  and  lymph  currents,  yet  the  returning 
or  downward  movement  may  with  benefit  lightly  graze  the  surface,  im- 
parting a  soothing  influence,  without  being  so  vigorous  as  to  retard  the 
circulation  pushed  along  by  the  upward  stroke,  and  thus  a  saving  of  time 
and  effort  will  be  gained.  The  manner  in  which  a  carpenter  uses  a 
plane  represents  this  forward-and-return  motion  very  well.  In  giving  a 
general  massage  it  is  immaterial  whether  the  upper  or  lower  extremities, 
be  done  first. 

Let  us  begin  with  the  hands,  and  here  a  convenient  extent  of  territory 
is  from  the  ends  of  the  fingers  to  the  wrist,  each  stroke  being  of  this 
length,  the  returning  stroke  being  light  and  without  removal  of  the 
hand.  The  rapidity  of  these  double  strokes  may  be  from  90  to  180 
a  minute.  The  whole  palmar  surface  of  the  fingers  in  easy  extension 
should  be  employed,  and  in  such  a  manner  that  they  will  fit  into  the 
depressions  formed  by  the  approximation  of  the  phalanges  and  meta- 
carpal bones,  the  patient's  hand  meanwhile  resting  in  the  other  hand 
of  the  manipulator,  the  right  in  the  right  and  the  left  in  the  left,  as  if 
placed  for  shaking  hands.  Six  to  a  dozen  up  and  return  strokes  may  be 
made  on  as  much  of  the  surface  of  the  back  and  palm  of  the  patient's 
hand  as  that  of  the  manipulator  will  cover.  As  there  will  be  a  small 
portion  left  undone,  the  hand,  or  rather  the  fingers,  of  the  manipulator 
will  be  placed  on  this  and  treated  in  a  similar  manner,  while  the  greater 
portion  of  the  surface  previously  worked  upon  will  at  the  same  time  and 
by  the  same  strokes  be  reviewed.  The  heel  of  the  hand  should  be  used 
for  vigorous  friction  of  the  palm,  done  by  a  semicircular  pushing  move- 


3l8        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

ment,  and  the  same  can  be  done  on  the  sole  of  the  foot  with  somewhat 
less  of  the  semicircular  motion.  The  effect  of  this  when  well  done  is 
remarkably  agreeable,  and  for  this  purpose  the  right  hand  of  the  opera- 
tor should  be  used  for  the  right  hand  and  the  foot  of  the  patient  and 
the  left  for  the  left,  for  in  this  manner  they  fit  each  other  best.  From 
the  wrist  to  the  elbow  and  from  the  elbow  to  the  shoulder-joint  are 
each  suitable  extents  of  surface  to  be  worked  upon,  and  here  not  only 
straight-line  friction,  extending  from  one  joint  to  another,  may  be  used,, 
but  also  circular  friction.  The  form  of  the  latter  which  appears  to  me 
most  serviceable,  as  it  includes  the  advantages  of  the  other  two,  is  that 
of  an  oval,  both  hands  moving  at  the  same  time,  the  one  ascending  as 
the  other  descends,  each  stroke  reaching  from  joint  to  joint,  the  up- 
ward being  carefully  kept  within  the  limits  of  chafing  the  skin,  while 
they  move  at  a  rate  of  from  75  to  180  each  a  minute,  or  150  to  360 
with  both  hands.  It  is  well  to  begin  these  strokes  on  the  inside  of  both 
arms  and  legs,  so  that  the  larger  superficial  and  deep  vessels  may  be 
first  acted  upon,  as  this  influence  extends  at  once,  though  indirectly, 
to  their  tributaries  and  ramifications.  But  it  is  not  always  practicable 
to  place  the  hand  of  the  patient  on  a  support  so  that  the  operator  can 
work  with  both  hands  on  the  arm.  If  not,  as  when  the  patient  is  lying 
down,  then  he  can  grasp  the  patient's  right  hand  by  its  dorsum  with  his 
left  while  his  other  does  oval  friction  on  the  anterior  aspect  of  the  arm. 
And  for  the  back  of  the  arm,  the  manipulator  will  grasp  the  patient's 
hand,  as  in  the  act  of  shaking  hands,  while  his  disengaged  hand  does 
the  friction. 

Time,  effort,  and  effect  will  be  made  the  most  of  by  doing  friction 
.upon  the  foot  with  the  hands  at  right  angles  to  it,  one  hand  upon  the 
dorsal  aspect,  and  the  other  upon  the  sole,  moving  alternately  and  in  a 
circular  manner,  the  one  ascending  as  the  other  descends.  Friction 
can  also  be  very  effectually  done  on  the  back  of  the  foot  by  the  manipu- 
lator sitting  in  front  of  the  patient,  when  alternate  up-strokes  can  be 
easily  made  with  each  hand  at  right  angles  to  the  foot  from  the  base  of 
the  toes  to  the  ankles.  Still  sitting  in  the  same  position,  one  hand  can 
grasp  the  back  of  the  foot  just  behind  the  toes — the  left  hand  for  the 
right  foot  the  right  hand  for  the  left  foot — while  the  other  hand,  mainly 
by  its  upper  portion  or  heel,  does  vigorous  friction  on  the  sole  from 
the  base  of  the  toes  to  the  heel.  Around  and  behind  the  malleoli  will 
require  a  special  pushing  stroke  with  the  fingers.  As  the  lower  limbs 
are  larger  than  the  upper,  the  lateral  and  posterior  aspects  from  ankle  to 
knee  will  form  a  convenient  territory,  while  the  lateral  and  anterior 
aspects  will  make  another  for  thorough  and  efficacious  friction.     This 


FRICTION 


319 


will  be  best  done  with  the  knees  semiflexed  and  the  manipulator  stand- 
ing facing  the  patient  for  the  posterior  and  lateral  aspects,  and  after 
having  completed  the  friction  here,  without  stopping  the  strokes,  he  will 
turn  with  his  back  to  the  patient  and  continue  the  stroking  on  the  an- 
terior and  lateral  aspects,  each  thumb  following  the  other  with  tolerably 
firm  pressure  over  the  anterior  tibial  group  of  muscles;  but,  owing  to 
the  latter  position  of  the  masseur,  only  upward  friction  can  be  done 
without  the  light  downward  stroke.  While  the  hand  on  the  inside  of 
the  leg  is  gliding  from  ankle  to  knee,  the  masseur  can  turn  without  losing 
a  second  of  time  or  an  inch  of  space. 

The  same  systematic  division  of  surface  may  be  made  above  the 
knee  as  below,  with  the  addition  of  another  formed  by  the  inner  and 
anterior  aspect  of  the  thigh,  and  they  may  be  dealt  with  in  like  manner; 
but  the  operator's  back  to  the  patient  will,  on  the  whole,  be  the  easiest 
and  most  efiScacious  way  of  applying  friction  to  the  thighs.  The  number 
of  strokes  below  the  knees  will  vary  from  100  to  160  with  each  hand; 
above,  from  60  to  100.  Back,  from  the  base  of  the  skull  to  the  spine 
of  the  scapula,  forms  another  region  naturally  well  bounded  for  down- 
ward and  outward  semicircular  friction,  and  from  the  spine  of  the 
scapula  to  the  base  of  the  sacrum  and  crest  of  the  ilium  forms  another 
surface  over  which  one  hand  can  sweep,  while  the  other  works  toward 
it  from  the  insertion  to  the  origin  of  the  glutei  at  an  average  rate  of  60 
or  75  a  minute  with  each  hand  for  a  person  of  medium  size.  It  will  be 
observed  that  on  the  back  and  thighs  the  strokes  are  not  so  rapid  as  on 
the  other  parts  mentioned,  for  the  reason  that  the  skin  here  is  thicker 
and  coarser,  in  consequence  of  which  the  hand  cannot  glide  so  easily, 
and  the  larger  muscles  beneath  can  well  bear  stronger  pressure;  besides, 
the  strokes  are  somewhat  longer,  all  of  which  require  an  increased  ex- 
penditure of  time.  For  more  thorough  and  special  effleurage  of  the  side 
of  the  neck,  as  when  we  are  deahng  with  an  acute  rheumatism  of  the 
upper  part  of  the  trapezius,  it  is  well  to  make  alternate  strokes  from 
the  base  of  the  skull  downward  and  inward  toward  the  chest,  on  the 
theory  that  the  circulation  takes  the  shortest  route  back  to  the  heart. 
And  we  desire  more  effectual  friction  on  the  hips  we  can  make  alternate 
strokes  in  a  semicircular  manner  from  the  insertion  to  the  origin  of 
the  glutei.  Indeed,  for  this  purpose  one  hand  can  make  continuous 
friction  in  a  circular  fashion,  while  the  other  does  the  alternate  supple- 
mentary semicircular  stroke.  The  chest  should  be  done  from  the 
insertion  to  the  origin  of  the  pectoral  muscles,  and  the  abdomen  from 
the  right  iliac  fossa  in  the  direction  of  the  ascending,  transverse,  and 
descending  colon.     But  in  these  situations  friction  is  seldom  necessary, 


320        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL    MOVEMENTS 

for  the  procedure  about  to  be  considered  accomplishes  all  that  friction 
can  do  and  a  great  deal  more.  The  force  used  in  doing  friction  is  often 
much  greater  than  is  necessary,  for  it  should  only  be  intended  to  act 
upon  the  skin,  as  there  are  better  ways  of  influencing  the  tissues  beneath 
it.  If  redness  and  irritation  be  looked  upon  as  a  measure  of  the  bene- 
ficial effects  of  friction  upon  the  skin,  then  a  coarse  tov;el,  a  hair  mitten, 
or  a  brush  would  answer  for  this  purpose  a  great  deal  better  than  the 
hand  alone.  But  for  intelligent  variation  of  pressure,  agreeableness  of 
contact,  and  adaptability  to  even  and  uneven  surfaces,  no  instrument 
has  yet  been  devised  to  supersede  the  human  hand.  In  union  there 
is  strength,  and  the  fingers  should  be  kept  close  together  in  doing  fric- 
tion and  manipulation.  But  it  is  astonishing  how  persistently  they  are 
sometimes  held  out  straight  and  spread  far  apart,  reminding  one  of  the 
feet  of  a  frightened  duck  in  a  thunder-storm,  and  the  sound  of  quack 
suggests  itself  as  appropriate  for  the  one  as  the  other.  This  would  be 
still  more  appropriate  when,  as  often  happens,  the  hands  are  made  to 
traverse  the  air  to  an  undue  extent,  accompanied  with  a  snapping  of 
the  fingers,  reminding  us  of  Mrs.  Boffin's  horses,  that  stepped  higher 
than  they  did  longways;  and  if  with  these  ungraceful  flourishes  perspira- 
tion be  mistaken  for  inspiration,  and  blind  enthusiasm  for  "magnetism," 
there  can  be  no  doubt  of  the  genus  to  which  the  operator  belongs. 

The  useless  flourishes  of  many  while  doing  friction  might  impress 
an  uninitiated  spectator  as  evidences  of  expertness.  They  bear  the  same 
relation  to  massage,  pure,  effectual,  and  agreeable,  that  the  superfluities 
of  architecture,  known  as  the  Queen  Anne  style,  w^herein  comfort  is 
sacrificed  to  beauty,  bear  to  the  classic  detail  of  Greek  architecture. 

MASSAGE 

The  advantages  of  ordinary  rubbing  are  not  to  be  despised,  and  by 
many  this  is  supposed  to  be  all  there  is  to  massage;  but  it  is  the  least 
essential  part  of  it.  One  of  the  old  French  dictionaries  says  there  is 
reason  to  believe  that  massage  has  upon  the  skin  the  advantage  of  fric- 
tion, that  it  acts,  above  all,  upon  the  more  deeply  situated  tissues,  etc., 
thus  implying  that  massage,  properly  so  called,  is  something  different 
from  friction,  and  yet  has  the  same  effect  upon  the  skin,  while  exerting 
a  more  extended  range  of  influence.  By  this  we  understand  massage 
proper  to  be  manipulation,  deep  rubbing,  kneading,  or  malaxation, 
which  is  certainly  the  most  important,  agreeable,  and  efficacious  pro- 
cedure of  all.  It  is  done  by  adapting  as  much  as  possible  of  the  fingers 
and  hands  to  the  parts  to  be  thus  treated,  and,  without  allowing  them 
to  slip  on  the  skin,  the  tissues  beneath  are  worked  upon  in  a  circulatory 


MASSAGE  321 

manner  by  a  sort  of  kneading,  rolling,  squeezing,  manipulatory  motion, 
proceeding,  as  in  friction,  from  the  insertioii  toward  the  origin  of  the 
muscles,  from  the  extremities  to  the  trunk.  For  this  purpose  the  same 
divisions  of  surface  as  for  friction  will  be  found  most  convenient.  Begin- 
ning, then,  with  the  fingers  from  the  roots  of  the  nails,  the  thumb 
of  the  manipulator  will  be  placed  on  one  of  the  fingers  of  the  patient 
and  parallel  to  it,  while  on  the  opposite  surface  the  second  phalanx  of 
the  index-finger  will  be  simultaneously  placed  at  right  angles  to  this, 
and  bet^veen  the  two  the  finger  of  the  patient  will  be  compressed  and 
malaxated  at  the  rate  of  from  75  to  150  a  minute.  The  dorsal  and 
palmar  surfaces  will,  of  course,  receive  special  attention,  while  the 
lateral  aspects  will  come  in  for  a  secondary  share.  If  the  manipulator 
be  sufficiently  expert,  he  can  work  with  both  hands  on  this  small  surface, 
one  in  advance  of  the  other,  or  he  can  take  one  of  the  patient's  fingers 
in  each  of  his  own  hands  and  proceed  with  the  same  rapidity  as  with 
one.  Each  finger  and  thumb  will  be  taken  in  turn,  and  the  manipula- 
tions extended  over  the  metacarpal  and  carpal  bones  as  far  as  the  wTist- 
joint,  and,  finally,  the  palm  of  the  hand  will  be  done  by  stretching  the 
tissues  vigorously  away  from  its  median  line.  The  muscles  between  the 
metacarpal  bones  are  not  very  effectually  reached  by  massage,  but  by 
pressing  up  with  the  fingers  in  the  palm  they  can  be  tolerably  worked 
upon  by  the  thumb  from  the  back  of  the  hand.  Each  part  included  in 
a  single  grasp  may  receive  3  or  4  manipulations  before  proceeding 
onward  to  the  adjacent  region,  and,  indeed,  3  manipulations  in  one  place 
and  three  times  over  the  part  that  is  being  masseed  makes  a  good  general 
rule,  here  and  elsewhere.  The  advance  upon  this  should  be  such  as 
to  allow  the  finger  and  thumb  to  overlap  one-half  of  what  has  just  been 
worked  upon.  Advance  and  review  should  thus  be  systematically  carried 
on,  and  this  is  of  general  application  to  all  the  other  tissues  that  can  be 
masseed.  The  force  used  here  and  elsewhere  must  be  carefully  gradu- 
ated so  as  to  allow  the  patient's  tissues  to  glide  freely  upon  each  other, 
for,  if  too  great,  the  movement  will  be  frustrated  by  the  compression 
and  perhaps  bursting  of  the  tissues;  if  too  light,  the  operator's  fingers 
will  sHp;  and  if  ghding  with  strong  compression  be  used,  the  skin  will 
be  chafed.  To  avoid  this  last  objection  various  greasy  substances  have 
been  employed,  so  that  ignorant,  would-be  masseurs  may  rub  without 
injuring  the  skin.  When  the  skin  is  cold  and  dry  or  cold  and  moist, 
and  the  tissues  in  general  are  insufficiently  nourished,  as  well  as  in 
certain  fevers  and  other  morbid  conditions,  there  can  be  no  doubt  of 
the  value  of  inunction,  but  no  special  skill  is  required  to  do  this,  and 
there  is  no  need  of  calling  it  massage,  unless  it  be  to  please  the  fancy  of 
21 


322        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

the  patient.  Removal  of  hair  is  entirely  unnecessary.  Massage  can 
be  done  as  effectuahy  on  the  head  as  on  any  other  part. 

The  feet  may  be  dealt  with  in  much  the  same  manner  as  the  hands, 
using  the  ends  of  the  fingers  to  work  longitudinally  between  the  meta- 
tarsal as  between  the  metacarpal  bones,  and  the  tissues  of  the  sole 
should  be  stretched  vigorously  away  from  the  median  line,  and,  lastly, 
the  heel,  accurately  adapted  into  the  palm  of  the  hand  and  between  the 
thenar  eminences  and  fingers,  will  be  worked  upon  in  a  squeezing, 
circulatory  manner. 

Upon  the  arms  and  legs  and,  indeed,  upon  all  the  rest  of  the 
body,  both  hands  can  be  used  to  better  advantage  than  where  the  sur- 
faces are  small.  Each  group  of  muscles  should  be  systematically  worked 
upon,  and  for  this  purpose  one  hand  should  be  placed  opposite  the  other, 
and  where  the  circumference  of  the  limb  is  not  great,  one  hand  may  be 
placed  in  advance  of  the  other,  the  fingers  of  one  hand  partly  reaching 
on  to  the  territory  of  the  other,  so  that  two  groups  of  muscles  may  be 
manipulated  at  the  same  time  with  grasping,  circulatory,  spiral  manipu- 
lations, one  hand  contracting  as  the  other  relaxes,  the  greatest  extension 
of  the  tissues  being  upward  and  laterally,  and  on  the  trunk,  forearms, 
and  legs  away  from  the  median  line.  It  is  needlessly  wearisome  to  both 
patient  and  manipulator  if  the  hands  are  kept  closely  adapted  to  a  limb 
its  whole  length  in  doing  this  vermicular  squeezing;  besides,  it  produces 
a  dragging  sensation  upon  the  skin  and  interferes  with  the  circulation. 
To  avoid  this,  it  is  only  necessary  to  raise  the  hands  slightly  in  advanc- 
ing. Subcutaneous  bony  surfaces,  as  those  of  tibia  and  ulna,  incident- 
ally get  sufficient  attention  (unless  edema  be  present)  while  manipulating 
their  adjacent  muscles,  for  if  both  be  included  in  a  vigorous  grasp,  un- 
necessary discomfort  results.  Care  should  be  taken  not  to  place  the 
fingers  and  thumb  of  one  hand  too  near  those  of  the  other,  for  by  so 
doing  their  movements  would  be  cramped.  With  the  fingers  and  thumbs 
at  proper  distances  from  each  other,  not  only  are  the  tissues  immediately 
under  them  acted  upon,  but  those  between  them  are  agreeably  stretched. 
The  advance  should  be  upon  the  previously  unoccupied  stretched  region. 
Space  and  force  will  be  indicated  by  the  elasticity,  or  want  of  it,  in  the 
patient's  tissues,  the  object  being  to  obtain  their  normal  stretch,  and  in 
this  every  person  is  a  law  to  himself,  the  character  of  tissues  varying 
with  the  amount  and  quality  of  adipose,  modes  of  life,  habits  of  exercise, 
etc.  A  frequent  error  on  the  part  of  the  manipulator  is  in  attempting 
to  stretch  the  tissues  in  opposite  directions  at  the  same  time,  especially 
at  the  flexures  of  the  joints,  where  the  skin  is  delicate  and  sensitive,  and 
where  the  temptation  to  such  procedure  is  greatest  because  easiest,  the 


MASSAGE 


323 


effect  being  a  sensation  of  tearing  of  the  skin.  It  is  well  to  go  over  a 
surface  gently  and  superficially  before  doing  the  manipulation  more 
thoroughly  and  in  detail.  In  the  case  of  the  forearm  the  two  hands 
will  embrace  the  whole  circumference,  one  in  advance  of  the  other,  the 
thumbs  occupying  the  median  line,  on  the  anterior  aspect,  while  the 
fingers  are  on  the  back  of  the  arm,  and,  after  going  over  this  in  a  three- 
times-three  manner,  the  forearm  should  then  be  pronated  and  the  thumbs 
placed  on  its  back,  which  will  be  similarly  treated,  the  fingers  meanwhile 
doing  their  share  of  the  work.  The  supinators  should  receive  a  special 
malaxation  with  the  grasp  of  one  hand.  Above  the  elbow,  one  hand 
will  seize  and  squeeze  the  biceps,  while  the  other  alternately  does  the 
same  to  the  triceps.  The  median  portion  of  the  deltoid  will  receive 
most  thorough  attention  from  the  thumbs  placed  parallel  to  its  fibers, 
while  the  palms  and  fingers  are  engaged  with  the  anterior  and  posterior 
aspects  of  the  muscles,  and  after  this  its  margins  and  the  whole  muscle 
can  be  well  worked  by  seizing  the  muscle  with  the  hand  at  right  angles 
to  its  fibers. 

In  manipulating  a  leg"  of  considerable  size  three  divisions  of  surface 
will  be  found  necessary:  the  posterior  and  lateral  aspects  will  form  one; 
the  stretching  of  the  peroneal  muscles  from  those  of  the  anterior  tibial 
region,  which  is  done  by  placing  one  thumb  in  advance  of  the  other  on 
each  side  of  the  fibula,  and  alternately  rolling  the  muscles  away  from 
each  other,  will  make  another;  and  for  the  third,  the  thumbs  will  be 
placed  upon  the  tibialis  anticus  and  a  simultaneous  rolling  of  the  tissues 
will  be  made  away  from  the  crest  of  the  tibia.  In  all  these  procedures 
no  parts  of  the  hands  need  be  idle,  for  when  not  specially  occupied, 
they  can  be  given  secondary  attention  to  the  surfaces  they  cover.  Of 
course,  if  the  limb  is  small,  it  can  all  be  masseed  at  once  in  the  grasp 
of  the  t\vo  hands,  but  even  in  this  case,  when  special  massage  is  required, 
these  three  divisions  are  necessary.  The  cushions  of  the  thumbs,  the 
heel  of  the  hand,  and  the  thenar  and  hypothenar  eminences  fit  admirably 
into  the  depressions  of  the  joints,  especially  those  of  the  ankle,  knee, 
and  elbow,  while  the  rest  of  the  hand  is  occupied  with  the  adjacent 
tissues.  Above  the  knee  one  hand  will  grasp  the  adductors  while 
the  other  embraces  the  quadriceps  extensor,  and  the  alternate  con- 
traction and  relaxation  of  the  hands  will  be  made  in  such  a  way  as  to 
stretch  these  two  groups  of  muscles  away  from  the  line  of  the  femoral 
artery.  The  posterior  femoral  region  may  next  be  gone  over,  which 
will  principally  engage  the  fingers  while  the  upper  parts  of  the  hands 
work  upon  the  sides  of  the  limbs,  or  the  patient  can  turn  on  the  chest 
and  abdomen,  when  very  effectual  kneading  with  the  thumbs  can  be 


324        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

given  to  the  muscles  of  the  back  of  the  thigh.  On  account  of  the  thick- 
ness and  tension  of  the  fascia  lata  the  external  aspect  of  the  thigh  may 
receive  as  vigorous  kneading  as  it  is  possible  to  give  with  evenly  dis- 
tributed force,  and  with  the  thumbs  in  advance  of  each  other  on  the 
rectus  femoris  more  special  and  effectual  manipulation  can  be  given 
to  the  extensors,  while  the  remaining  surfaces  of  the  hands  make  a 
review  of  the  lateral  aspects  of  the  thigh.  The  hip  should  be  masseed 
from  the  insertion  to  the  origin  of  the  glutei,  from  the  back  of  the  thigh 
to  the  sacro-iliac  articulation,  and,  lastly,  the  glutei  should  be  simultan- 
eously stretched  away  from  the  origin.  The  rate  of  these  maneuvers 
varies  from  75  to  150,  with  each  hand  a  minute  on  the  arms,  from  60 
to  90  on  the  legs,  and  from  40  to  80  on  the  thighs,  where  more  force  is 
required  on  account  of  the  larger  size  and  density  of  the  muscles  and 
the  need  of  using  sufficient  force  to  extend  beneath  the  strong,  tense 
fascia  lata. 

On  the  back  the  direction  of  these  efforts  will  be  from  the  base  of 
the  skull  downward,  stretching  the  tissues  away  from  the  spinal  column 
while  manipulating  in  graceful  curves  at  an  average  rate  of  60  a 
minute  with  each  hand.  If  this  be  done  on  one  side  of  the  back,  as  it 
most  frequently  has  to  be,  while  the  patient  lies  on  the  other  side,  it  is 
one  of  the  most  difficult  maneuvers  for  beginners  to  learn  and  some 
never  succeed  in  acquiring  it.  While  both  hands  are  at  work  on  separate 
spaces  occupied  by  each,  the  one  follows  the  other,  not  in  an  opposite, 
but  in  the  same  circular,  m.anner  alternately,  the  one  contracting  as  the 
other  relaxes.  The  back  is  most  effectually  masseed  with  the  patient 
lying  on  one  side,  for  in  this  position  the  ribs  and  transverse  processes 
form  a  better  substratum  than  when  the  patient  lies  on  the  chest  and 
abdomen.  On  stout  patients  with  firm  tissues  one  hand  should  often 
be  reenforced  by  placing  the  other  upon  it,  and  thus  the  massage  may 
be  done  with  all  the  strength  the  manipulator  can  put  forth.  The 
position  of  the  shoulder-blades  is  important,  for  if  the  upper  arm  be 
parallel  with  the  side,  then  the  posterior  border  of  the  shoulder-blade 
will  be  so  near  the  spinal  column  that  scarcely  any  space  will  be  allowed 
to  work  upon  the  muscles  between  the  scapula  and  spine.  If  the  upper 
arm  be  stretched  forward  its  full  length,  then  the  superficial  muscles 
between  the  spine  and  the  scapula  wnll  often  be  so  tense  that  those 
beneath  cannot  be  effectually  reached  by  massage.  Hence,  the  arm 
should  be  placed  midway  between  these  two  positions.  With  the  ends 
of  the  fingers  the  muscles  on  each  side  of  the  spinal  column  can  be 
rolled  outward,  and  the  supraspinous  ligament  can  be  effectually  mas- 
seed by  transverse  to-and-fro  movements.     The  ends  of  the  fingers  and 


MASSAGE  325 

part  of  their  palmar  surface  should  also  be  placed  on  each  side  of  the 
spinous  processes,  and  the  tissues  situated  between  these  and  the  trans- 
verse processes  worked  by  up-and-down  motions  parallel  to  the  spine, 
taking  care  to  avoid  the  too  frequent  error  of  making  pushing,  jerky 
movements  in  place  of  smooth,  uniform  motions  in  each  direction. 
With  the  patient  lying  face  down  it  is  sometimes  well  to  finish  off  the 
back  by  adapting  the  hands  with  their  w^hole  surface  to  each  side  of  the 
spinal  column. 

On  the  chest  and  abdomen  the  same  general  direction  will  be 
observed  as  in  using  friction,  but  the  manipulation  will  be  more  gentle 
than  on  the  back  and  limbs,  for  the  tissues  will  not  tolerate  being  so 
vigorously  squeezed  and  pinched.  Here  the  massage  will  consist  of 
moderate  pressure  and  movement  with  the  palms  of  the  hands  and  rolling 
and  grasping  the  skin  and  superficial  fascia;  and,  after  this,  on  the 
abdomen,  firm,  deep  kneading  in  the  direction  of  the  ascending,  trans- 
verse, and  descending  colon,  using  for  this  purpose  the  greatest  force 
with  the  heel  of  the  hand  on  the  side  of  the  abdomen  next  the  operator 
and  on  the  other  side  the  strongest  manipulation  with  the  fingers,  avoid- 
ing the  frequent  and  disagreeable  mistake  of  pressing  at  the  same  time 
on  the  anterior  portions  of  the  pelvis.  The  sides  w^ill  incidentally  re- 
ceive sufficient  attention  while  the  back,  chest,  and  abdomen  are  being 
manipulated.  When  constipation  is  obstinate,  it  is  a  good  plan  to  com- 
mence manipulation  of  the  abdomen  over  the  left  venter  of  the  ilium 
and  work  so  as  to  push  the  contents  of  the  descending  colon  toward  the 
rectum;  then  begin  again  a  little  farther  backward  on  the  colon  and 
work  in  the  same  direction  as  before,  attempting  to  unload  the  large 
intestine,  and  so  on  until  the  whole  colon  is  traversed  back  to  the  ileo- 
cecal valve,  and  again  from  there  to  the  sigmoid  flexure  of  the  colon. 

Except  on  the  muscles  of  the  back,  massage  by  rollers  is  of  little  use 
in  comparison  with  that  by  hand.  They  may  be  made  of  rubber,  wood, 
or  metal,  of  any  size,  shape,  or  color  to  suit  the  fancy  of  the  so-called 
inventor.  I  have  had  several  sorts  and  sizes  made,  and  find  that  toler- 
ably fair  and  rapid  rolling  of  the  muscles  of  the  back  may  be  done  by 
means  of  a  rubber  roller  3  in.  in  length  and  I7}  in.  in  diameter,  secured 
to  a  handle  like  that  of  a  printer's  ink-roller.  Wooden  rollers,  2  in.  long 
and  i|  in.  in  diameter,  of  a  somewhat  oval  or  spindle-shaped  construction, 
made  so  as  to  revolve,  not  only  on  their  own  axes,  but  also  on  the  handles 
to  which  they  are  attached,  do  very  well  for  the  backs  of  people  who 
are  too  lazy  to  take  off  their  clothes. 

The  wire  of  either  pole  of  any  electric  battery  or  machine  can  easily 
be  attached  to  a  conducting  roller  with  a  non-conducting  handle,  but 


326        FRICTION,   MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

the  sponges  or  poles  of  any  battery  may  be  pressed  and  moved  so  as 
to  give  a  kind  of  massage  while  the  current  is  passing,  and  this  is  much 
more  agreeable  and  effectual  than  a  current  from  a  metallic  roller,  or 
one  pole  may  be  attached  to  the  patient,  the  other  to  the  manipulator, 
while  the  latter  does  massage  with  the  current  passing  through  both  of 
them,  but  the  so-called  "electro-massage"  is  hardly  worthy  of  the  name 
of  massage.  Professor  Zabludowski  used  to  scorn  the  idea  of  doing 
anything  worthy  of  the  name  of  massage  with  instruments  or  machinery, 
and  asserted  that  only  in  the  hands  of  physicians  would  it  prove  to  be 
an  effectual  curative  means.  More  recently,  however,  he  sometimes 
uses  instruments  for  the  purpose  of  giving  a  rapid  rate  of  percussion  for 
affections  of  the  heart,  nerves,  etc. 

Before  leaving  this  part  of  the  subject,  the  writer  begs  leave  to  say 
something  more  about  the  common  errors  into  which  manipulators  fall, 
even  some  of  those  who  pass  for  being  skilful.  Many  do  not  know  how 
to  do  the  kneading  or  malaxation  with  ease  and  comfort  to  themselves 
and  to  their  patients,  for,  in  place  of  working  from  their  wrists  and 
concentrating  their  energy  in  the  muscles  of  their  hands  and  forearms, 
they  vigorously  fix  the  muscles  of  their  upper  arms  and  shoulders,  thus 
not  only  moving  their  own  frame  with  every  manipulation,  but  also 
that  of  their  patients,  giving  to  the  latter  a  motion  and  sensation  as  if  they 
were  at  sea  in  stormy  weather.  By  this  display  of  awkward  and  un- 
necessary energy  not  only  do  they  soon  tire  themselves  out,  and  fancy 
that  they  have  lost  magnetism  by  imparting  it  to  their  patients,  but  by 
the  too  firm  compression  of  the  patient's  tissues  they  are  not  allowed 
to  glide  over  each  other,  and  hence  such  a  way  of  proceeding  entirely 
fails  of  the  object  for  which  it  is  intended.  Surely,  cultivation  is  the 
economy  of  effort,  and  the  most  perfect  art  consists  in  acting  so  naturally 
that  it  does  not  appear  to  be  any  attem.pt  at  art  at  all.  The  following 
words  of  J.  Milner  Fothergill  are  hence  applicable:  "The  knowledge 
which  one  man  acquires  by  the  sweat  of  his  brow  after  years  of  patient 
toil  and  painstaking  cannot  be  transferred  in  its  entirety  to  another. 
Individual  acquired  skill  cannot  be  passed  from  brain  to  brain  any  more 
than  the  juggler  who  can  keep  six  balls  in  the  air  can  endow  an  onlooker 
with  like  capacity  by  merely  showing  him  how  it  is  done.  The  muscles, 
and  still  more  their  representatives  in  the  motor  area  of  the  brain  hemis- 
pheres, require  a  long  training  before  this  manual  skill  can  be  acquired." 

Friction  and  manipulation  can  be  used  alternately,  varied  with 
rapid  pinching  of  the  skin  and  deeper  grasping  of  the  subcutaneous 
cellular  tissue  and  muscular  masses,  and  when  necessary  with  percus- 
sion, passive,  assistive,  or  resistive  movements,  finishing  one  conveni- 


»  PERCUSSION  327 

ent  surface  or  limb  before  passing  to  another,  and  occupying,  from  half 
an  hour  to  an  hour  with  all  or  part  of  these  procedures.  Pinching  is 
rather  an  agreeable  way  of  exciting  the  circulation  and  innervation  of 
an  inert  skin,  and  for  this  purpose  it  is  best  done  rapidly,  at  the  rate  of 
100  to  125  a  minute  with  each  hand.  The  grasp  of  a  fold  of  skin 
should  not  be  relaxed  until  seized  by  the  finger  and  thumb  of  the  other 
hand.  To  act  upon  the  subcutaneous  cellular  tissue,  a  handful  of  skin 
is  grasped  and  rolled  and  stretched  more  slowly  than  by  the  preceding 
method.  A  deeper,  momentary  grasping  of  the  muscles  is  often  ad- 
vantageous, and  may  be  called  a  mobile  intermittent  compression,  and 
this,  indeed,  is  what  the  whole  of  massage,  strictly  speaking,  consists  of. 

PERCUSSION 

Percussion,  in  general  applicable  only  over  muscular  masses,  may 
be  done  in  various  ways.  In  the  relative  order  of  their  importance  they 
are  as  follow^s:    (i)  With  the  ulnar  borders  of  the  hands  and  fingers. 

(2)  The  same  as  the  first,  but  with  the  fingers  separated  so  that  their 
adjacent  sides  will  strike  against  each  other  like  a  row  of  ivory  balls. 

(3)  With  the  ends  of  the  fingers,  the  tips  being  united  on  the  same  plane. 

(4)  With  the  dorsum  of  the  upper  halves  of  the  fingers  loosely  flexed. 

(5)  With  the -palms  of  the  hands.  (6)  With  the  ulnar  borders  of  the 
hands  lightly  shut.  (7)  With  the  palms  of  the  hands  held  in  a  concave 
manner,  so  as  to  compress  the  air  while  percussing.  The  back  of  a 
brush  or  the  sole  of  a  slipper  sometimes  answers  very  well  for  percussion, 
but,  still  better,  are  india-rubber  air-balls  secured  to  steel  or  whalebone 
handles.  With  these  one  gets  the  spring  of  the  handles  together  with 
the  rebound  of  the  balls,  and  thus  rapidity  of  motion  with  easily  varying 
intensity  may  be  gained,  if  the  operator  knows  how  to  let  his  wrists  play 
freely,  as  he  should  do  in  all  the  different  ways  of  percussing.  The 
number  of  blows  may  vary  from  250  to  600  with  both  hands.  The 
blows  should  be  smart,  quick,  and  springy,  not  solid  and  hard,  and 
they  should  be  transversely  to  the  course  of  the  muscles  with  the  ulnar 
border  of  the  hand  and  palmar  surface;  except  in  the  case  of  the  back, 
which  may  not  only  be  percussed  with  the  hands  at  right  angles  to  it 
while  the  patient  is  lying  but  still  more  effectually  when  the  patient 
is  standing  bent  forward,  so  as  to  put  the  dorsal  muscles  on  the  stretch. 
The  operator's  hands  are  then  most  easily  parallel  to  the  spine,  and  can 
rapidly  strike  the  muscles  on  each  side  of  it,  causing,  we  have  reason 
to  suppose,  a  vibratory  effect,  as  when  the  string  of  a  bow  is  vibrated. 
Moreover,  in  this  position  the  muscles,  being  tense,  protect  the  trans- 
verse processes  from  the  impact  of  the  blows  which  is  communicated 


328        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

to  the  nerves  as  they  emerge  from  the  intervertebral  foramina,  and  the 
effect  is  usually  perceived  to  their  distributions  all  over  the  body  as  a 
peculiar  and  delightful  thrill.  Percussion  must  be  carefully  used  or 
it  will  leave  the  muscles  lame  and  sore. 

REMEDIAL  MOVEMENTS 

Remedial  movements  have  been  more  fully  than  clearly  described 
in  books  on  "Movement  Cure."  A  comparison  of  different  ways  of 
executing  them  demonstrates  that  the  part  of  the  limb  or  body  taken 
hold  of  for  leverage,  and  the  manner  of  seizing  the  same,  the  direction 
of  resistance  and  force  opposed,  are  all  of  importance  in  order  that  the 
movements  may  be  done  easily,  efficaciously,  and  harmoniously.  Those 
who  would  apply  them  should  know  the  anatomy  and  physiology  of  the 
joints  of  their  natural  limits  of  motion.  Except  in  the  case  of  relaxed 
joints,  passive  motion  should  be  pushed  until  there  is  a  feeling  of  slight 
resistance  to  both  patient  and  manipulator,  for  by  this  it  will  be  known 
that  in  healthy  joints  the  ligaments,  capsules,  and  attachments  of  the 
muscles  and  fasciae  are  being  acted  upon.  Resistive  movements  are 
such  as  the  patient  can  make  while  the  operator  resists,  or  such  as 
the  operator  overcomes  when  the  patient  resists,  as  when  a  group  of 
muscles  is  voluntarily  contracted  the  operator  extends  them.  The 
former  have  been  called  double  concentric  movements  and  the  latter 
double  eccentric.  It  seems  to  me  that  the  author  of  these  terms  must 
have  been  somewhat  eccentric,  for  even  so  good  a  writer  as  Estradere 
pardonably  confounds  their  meaning,  as  can  be  seen  by  comparing  his 
explanation  of  them  on  page  72  with  that  on  page  80  of  his  book  on 
"Massage."  Brown-Sequard  first  pointed  out  the  fact  to  me  that  when 
it  is  desirable  to  exercise  a  group  of  very  much  enfeebled  muscles,  if 
they  first  be  contracted  to  their  utmost  it  will  require  much  greater 
force  to  overcome  this  contraction  than  they  could  overcome  in  passing 
from  a  state  of  relaxation  to  contraction,  and  I  have  since  proved  the 
practical  value  of  the  suggestion.  Most  frequently,  however,  it  will 
be  necessary  to  offer  resistance  against  the  patient's  movements,  and 
then  the  opposing  force  should  be  carefully  and  instinctively  kept  within 
the  limits  of  the  patient's  strength,  so  that  he  may  not  recognize  any 
weakness,  and  this,  with  all  these  other  maneuvers,  should  stop  short 
of  fatigue,  at  least  fatigue  that  is  not  soon  recovered  from.  To  alter- 
nately resist  flexion  and  extension  is  the  pons  asinorum  of  manipulators, 
and  in  a  considerable  experience  of  teaching  massage  I  have  found 
but  few  who  could  learn  to  do  it  w^ell  and  many  who  could  not  learn 
to  do  it  at  all.     Many  a  patient  who  has  recovered  from  an  old  injury 


REMEDIAL   MOVEMENTS  329 

is  still  as  much  incapacitated  as  ever  from  the  fact  that  his  latent  energies 
can  only  be  discovered  and  made  available  in  this  manner.  Midway 
between  passive  and  restive  movements,  in  the  course  of  certain  recoveries, 
stand  assistive  movements.  They  are  but  little  understood  and  seldom 
used.  Let  it  be  supposed  that,  in  the  absence  of  adhesions  and  irreparable 
injury  of  the  nerve-centers,  the  deltoid  has  but  half  the  requisite  strength 
to  raise  the  arm.  So  far  as  any  use  is  concerned,  this  is  the  same  as  if 
there  were  no  power  of  contraction  left  in  the  muscle.  But  if  only  the 
other  half  of  the  impaired  vigor  be  supplemented  by  the  carefully  grad- 
uated assistance  of  the  operator,  the  required  movement  will  take  place; 
and,  in  some  cases,  if  this  be  regularly  persisted  in,  together  with  manipu- 
lation and  percussion,  more  vigorous  contraction  will  be  gained,  and, 
by  and  by,  the  patient  will  exert  three-fourths  of  the  necessary  strength, 
and  later  the  whole  movement  will  be  done  without  aid,  and,  as  strength 
increases,  resistance  can  be  opposed  to  the  movement.  The  importance 
of  these  measures  can  hardly  be  overestimated  in  cultivating  the  strength 
of  weakened  muscles  while  at  the  same  time  finding  out  how  much 
they  can  be  used.  Still  another  kind  of  movement  may  be  spoken  of — 
namely,  vigorous  passive  motion — ^with  a  view  to  breaking  up  adhesions 
in  and  about  joints.  It  is  the  secret  of  success  and  of  failure  of  the 
people  who  call  themselves  "bone-setters,"  the  methods  of  whom  have 
been  well  studied  and  explained  by  Dr.  Wharton  P.  Hood,  of  London, 
in  his  highly  entertaining  book  "  On  Bone-setting,  So-called." 

So  much  for  a  general  outline  of  movements.  Let  us  speak  of  them 
more  in  detail.  In  doing  a  resistive  movement  in  which  the  patient  is 
the  prime  mover  the  masseur  waits  until  he  finds  the  movement  begun, 
then  gradually  increases  the  resistance  to  the  utmost  within  the  limits 
of  the  patient's  strength,  and  finally  slacks  up  more  slowly.  This  must 
be  practised  by  the  manipulator  on  well  people  until  he  can  instinctively 
judge  of  the  patient's  strength  and  make  elastic  resistance.  The  re- 
sistance must  be  in  hne  with  the  patient's  movements,  and  the  grasp 
of  the  operator  must  not  be  so  firm  as  to  interfere  with  his  own  sensation 
or  that  of  the  patient.  It  will  often  be  found  that  the  patient  uses  nearly 
all  his  strength  in  contracting  his  muscles  and  scarcely  any  in  overcoming 
the  resistance,  in  which  event  it  will  be  necessary  to  tell  him  to  move 
more  quickly  and  not  try  so  hard.  Here  physiology  steps  in  and  gives 
us  a  reason  for  the  faith  that  is  in  us,  showing  how  science  agrees  with 
art.  Muscular  contraction  presents  three  phases:  (i)  A  preparatory 
or  latent  period,  during  which  there  is  no  visible  movement  when  the 
nerve  and  muscle  are  getting  ready  to  act.  (2)  A  phase  of  shortening 
or  contraction.     (3)  That  of  relaxation  or  return  to  its  former  length. 


330        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

In  harmony  with  these  phenomena,  and  with  the  manner  of  doing  each 
and  all  of  the  manipulations,  and  especially  resistive  movements,  physi- 
ology teaches  us  that  at  the  close  of  the  latent  period  the  muscles  shorten 
in  each  fiber,  at  first  slowly,  then  more  rapidly,  and  lastly  more  slowly 
again.  In  accordance  with  these  physiologic  principles  of  muscular 
contraction  it  would  be  difiicult  to  conceive  of  anything  that  would 
make  graduated  and  harmonious  resistance  save  human  power  guided 
by  human  intelligence.  Springs  and  elastic  contrivances  come  nearest 
to  it  and  do  very  well  on  starting,  but  the  longer  the  pull  or  push,  the 
stronger  becomes  the  opposition,  and  there  is  no  third  stage  of  lessened 
resistance. 

The  manner  of  taking  the  hand  to  give  it  passive  motion  of  flexion 
and  extension  and  to  resist  flexion  is  the  same.  Let  the  patient's  fore- 
arm be  midway  between  pronation  and  supination,  and  then  seize  the 
hand  as  if  about  to  shake  hands,  the  right  hand  for  the  right  hand  of  the 
patient  or  the  left  for  the  left,  so  as  to  bring  the  resistance  on  a  line  with 
the  metacarpophalangeal  joints,  which  affords  the  best  leverage  for  both 
patient  and  operator;  the  other  hand  at  the  same  time  will  support 
and  make  counterresistance  on  the  back  of  the  arm  about  i  in.  above 
the  wrist.  To  resist  extension  of  the  hand  the  patient's  forearm  should 
be  pronated,  then  the  operator  will  take  the  hand  in  such  a  way  as  to 
bring  the  resistance  over  the  heads  of  the  metacarpal  bones,  his  right 
hand  for  the  patient's  left  and  the  left  for  the  right,  while  the  other 
supports  and  steadies  the  arm  above  the  wrist  on  the  anterior  surface. 
For  passive  pronation  and  resistive  supination  the  manner  of  holding 
the  arm  is  the  same;  the  operator's  right  hand  seizes  the  left  wrist  and 
lower  ends  of  the  radius  and  ulna  of  the  patient  so  that  the  metacarpo- 
phalangeal joint  of  his  thumb  is  upon  and  behind  the  styloid  process  of 
the  radius,  the  point  of  resistance,  care  being  taken  not  to  squeeze  so 
tightly  as  to  prevent  these  bones  from  rotating  upon  each  other;  in 
the  mean  time  the  other  hand  of  the  operator  gently  supports  the  arm 
of  the  patient.  For  passive  supination  or  resistive  pronation  the  same 
grasp  suffices,  with  the  right  hand  of  the  manipulator  for  the  right  arm 
of  the  patient,  or  the  left  for  the  left,  which  seizes  the  wrist  and  lower 
ends  of  the  radius  and  ulna  so  that  the  metacarpo-phalangeal  joint  of 
the  thumb  is  anterior  to  the  styloid  process  of  the  radius,  the  same  care 
being  observed  not  to  hinder  the  motion  by  holding  too  tightly,  while 
the  arm  of  the  patient  rests  in  the  other  hand  of  the  operator.  For 
passive  or  resistive  motion  of  the  forearm  the  right  wrist  of  the  patient 
is  gently  held  by  the  right  hand  of  the  operator,  while  the  left  hand 
steadies  the  arm  just  above  the  condyles  of  the  humerus,  and  the  same 


REMEDIAL   MOVEMENTS 


33'^ 


grasp  suflSces  for  the  passive  combined  motion  of  flexion,  extension, 
pronation  and  supination,  abduction  and  adduction,  together  with  rota- 
tion of  the  humerus,  all  of  these  seven  last  movements  being  accomplished 
at  one  and  the  same  time  by  simply  making  the  wrist  describe  a  circle. 
Circumduction  of  the  humerus  is  most  easily  and  effectually  done  by 
standing  behind  the  patient,  and,  while  fixing  the  right  shoulder  with 
the  left  hand  or  the  left  with  the  right,  the  other  hand  takes  the  arm 
just  below  the  elbow  and  makes  this  traverse  as  great  a  circle  as  moderate 
resistance  will  allow,  the  operator  remembering  that  the  greatest  re- 
sistance will  be  at  the  upper  and  outer  third  of  the  circle,  owing  to  the 
natural  formation  of  the  joint.  The  same  hold  and  support  answer 
well  for  resisting  a  forward  motion  of  the  upper  arm.  If  the  patient 
be  lying  on  the  right  side,  or  the  operator  be  standing  in  front  of  the 
patient  while  the  latter  is  sitting,  tolerably  good  circumduction  may  be 
done  by  taking  the  left  wrist  in  the  left  hand  and  placing  the  right  hand 
upon  the  elbow.  But  this  is  not  so  effectual  as  the  first  method,  owing 
to  the  great  mobility  of  the  scapula.  Backward  motion  of  the  humerus 
can  be  steadily  and  definitely  resisted  by  taking  the  right  hand  of  the 
patient  in  the  right  hand  of  the  operator,  or  the  left  with  the  left,  while 
the  other  is  placed  at  the  back  of  the  forearm,  not  to  pull,  but  only  to 
steady  the  movement.  The  action  of  the  deltoid  in  elevating  the  arm 
can  be  well  resisted  by  steadying  the  shoulder  with  one  hand  while 
the  other  is  placed  on  the  outside  of  the  upper  arm,  and  the  opposition 
can  easily  be  increased  by  moving  the  hand  toward  the  elbow  or  dimin- 
ished by  moving  the  hand  toward  the  shoulder,  the  operator  mean- 
while standing  behind  the  patient.  Standing  in  the  same  position,  with 
the  inner  condyle  of  the  humerus  in  the  middle  of  the  palm,  the  mas- 
seur can  resist  downward  motion  of  the  patient's  upper  arm,  a  most 
admirable  procedure  to  tire  the  muscles  when  we  have  to  deal  with  a 
weak  deltoid.  When  it  is  desired  to  limit  motion  to  one  joint,  it  will  be 
observed  that  the  proximal  side  should  be  steadied  while  the  distal 
side  is  moved,  and  nowhere  is  this  more  disregarded  than  with  the 
fingers. 

For  passive  or  resistive  motion  of  the  ankle-joint  the  best  way  of 
taking  hold  is  not  by  seizing  the  heel  with  one  hand  while  the  other 
surmounts  the  toes,  as  is  generally  done,  but  with  the  right  hand  for  the 
right  foot  or  the  left  hand  for  the  left  foot,  by  grasping  the  metatarso- 
phalangeal joints  at  right  angles  while  the  other  hand  supports  the  leg 
above  the  ankle.  For  this  purpose  the  operator  should  sit  facing  the 
patient  and  be  careful  that  his  active  arm  is  in  a  straight  line  with  the 
patient's  movement.     This  affords  the  best  leverage  for  flexion  and 


332        FRICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

extension  of  the  foot,  as  well  as  for  a  circumductory  motion,  by  making 
the  place  of  seizure  describe  a  circle,  the  outer  half  of  which  will  offer 
the  greatest  resistance,  owing  to  the  large  internal  lateral  ligament  and 
the  stronger  structures  on  the  inside  of  the  joint.  The  same  hold 
answers  for  resisting  flexion  and  extension  of  the  foot.  When  this  is 
done  alternately,  in  the  interval  of  change,  here  and  elsewhere,  the  hand 
of  the  operator  must  alter  its  position  slightly  so  as  to  present  a  proper 
surface  for  resistance.  In  the  case  of  the  foot  and  forearm,  the  fingers 
will  pull  and  resist  flexion  and  the  heel  of  the  hand  will  push  against 
extension.  On  the  foot  the  tendency  is  to  make  resistance  too  near  the 
toes;  opposite  the  heads  of  the  metatarsal  bones  on  the  back  and  sole 
are  the  points  that  afford  the  best  and  most  natural  leverage.  By 
seizing  the  heel  and  holding  the  ball  of  the  foot,  as  just  described  for 
passive  motion,  a  toasting  motion  can  be  given  to  the  whole  foot  which 
acts  more  decidedly  on  the  tarsal  and  metatarsal  articulations.  Flexion 
and  extension  of  the  leg  at  the  knee,  either  passively  or  resistively,  are 
seldom  necessary  to  be  done  alone  (except  for  some  special  reason), 
as  they  are  accomplished  so  much  better  together  with  flexion  and  ex- 
tension of  the  thigh;  and  for  this  purpose  the  right  heel  of  the  patient  is 
taken  in  the  palm  of  the  right  hand  of  the  operator,  or  the  left  in  the  left, 
while  the  other  hand  holds  the  calf,  and  a  steady  uniform  push  is  made, 
the  limb,  by  its  own  resiliency,  usually  returning  to  a  state  of  extension. 
Circumduction  of  the  thigh  will  be  performed  by  simply  changing  the 
hand  that  holds  the  calf  on  to  the  top  of  the  knee,  which  affords  excellent 
and  easy  leverage.  On  each  side  of  the  forefinger  of  the  hand  that 
manages  the  heel  the  covering  will  be  held  by  the  thumb  and  middle 
finger,  so  that  the  patient  may  not  be  fanned  into  the  next  world.  Op- 
posing flexion  and  extension  of  the  leg  and  thigh  may  be  done  by  holding 
the  leg  and  foot  as  for  passive  or  resistive  movements  of  the  ankle,  and 
if  the  couch  on  which  the  patient  lies  be  low,  the  manipulator  will  often 
require  to  rest  on  the  knee  next  the  patient  on  the  floor,  and  resisting 
extension  will  throw  the  weight  of  his  body  in  part  or  wholly  against 
the  extending  limb,  and  in  doing  this  the  arm  must  not  be  extended 
but  flexed,  so  as  to  bring  the  hand  as  near  as  possible  to  the  shoulder 
in  order  that  the  resistance  may  be  strong  and  steady  by  having  the 
weight  of  the  body  added  to  it;  or  he  can  stand  with  his  back  to  the 
patient  and  clasp  his  hands  on  the  sole  of  the  arch  to  resist  extension. 
Resisting  extension  of  leg  or  thigh  is  hard  for  the  manipulator,  easy 
for  the  patient.  On  the  other  hand,  resisting  flexion  of  the  leg  and 
thigh  is  easy  for  the  masseur,  hard  for  the  patient,  and  both  should 
remember  that  these  must  not  degenerate  into  play  in  order  to  see  which 


REMEDIAL   MOVEMENTS 


333 


is  the  stronger;  6  to  12  carefully  graduated  pushes  and  pulls  in  each 
direction,  either  successively  or  alternately,  may  be  done.  Opposing 
abduction  and  adduction  of  the  thighs  scarcely  needs  mention,  so  simply 
are  they  done  by  alternately  placing  the  hands  on  the  outer  and  inner 
aspects  of  the  semiflexed  knees;  and  to  resist  the  contraction  of  the 
psoas  magnus  and  iliacus  internus  alone,  resistance  may  be  made  to 
the  flexing  thigh  on  any  part  of  its  anterior  aspect. 

Passive  stretching  of  the  arms  and  shoulders,  of  the  pectoral  muscles 
and  latissimus  dorsi,  can  be  done  agreeably  and  effectually  while  the 
patient  lies  squarely  on  the  back,  the  head  and  shoulders  being  slightly 
elevated  on  an  inclined  plane.  The  arms  of  the  patient  are  extended 
upward  on  a  line  with  the  body,  and  the  manipulator,  standing  behind, 
holding  the  hands,  makes  a  gentle,  elastic,  and  vigorous  pull;  and  if 
the  feet  be  held,  a  stretch  of  the  trunk  and  lower  limbs  can  also  be 
obtained. 

The  manner  of  seizing  the  hands  of  the  patient  for  this  purpose  is 
worthy  of  particular  notice.  They  are  grasped  so  that  their  palmar 
surfaces  obliquely  cross  the  palmar  surfaces  of  the  operator,  the  fingers 
of  the  manipulator  surround  the  metacarpal  region  of  the  thumb,  while 
the  thumb  of  the  operator  passes  between  the  thumb  and  index-finger 
of  the  patient,  and  the  heel  of  the  hand  rests  securely  upon  the  meta- 
carpal region  of  the  patient's  little  finger,  so  that  the  hands  of  the  patient 
and  manipulator  are  complementary  to  each  other.  This  is  a  puzzle 
for  most  people  to  do,  even  after  having  seen  it  done.  The  same  hold 
suffices  for  resisting  a  dowmvard  pull  of  the  arms,  which  brings  the  afore- 
said muscles  more  strongly  into  play,  elevates  the  chest,  and  deepens 
inspiration.  With  the  patient  sitting  slightly  inclined  forward,  the 
hands  clasped  at  the  back  of  the  head,  the  oblique  and  transverse  muscles 
of  the  abdomen  can  be  passively  exercised  by  seizing  the  patient  at 
or  near  the  shoulder-joints  and  rotating  the  body,  the  manipulator,  of 
course,  standing  behind  the  patient.  The  same  position  of  the  patient 
does  well  to  make  these  muscles  act  more  vigorously  by  opposing  their 
voluntary  contraction.  In  doing  this  the  masseur  stands  behind  and  to 
one  side  of  the  patient,  steadying  the  body  of  the  latter  with  the  left  hand 
upon  the  left  shoulder  or  the  right  hand  upon  the  right,  at  the  same  time 
that  the  other  hand  holds  the  -humerus  near  the  elbow,  by  which  great 
leverage  is  obtained  in  resisting  rotation  of  the  trunk.  At  first  the 
patient  wilf  naturally  err  in  limiting  the  motion  of  the  arms  and  chest, 
but  he  can  be  gradually  educated  to  lessen  this  and  increase  the  rota- 
tion at  the  waist.  Upon  a  vigorous  and  healthy  tone  of  the  muscles 
of  the  abdomen  depends  to  a  large  extent  the  welfare  of  the  organs 


334        TEICTION,    MASSAGE,    PERCUSSION,    REMEDIAL   MOVEMENTS 

situated  beneath  them,  and  no  muscles  are  so  much  "left  out  in  the  cold" 
for  want  of  exercise  as  these.  Gentle  rowing  exercise  for  the  muscles 
of  the  back  can  be  given  to  invalids  by  standing  in  front  of  them  and 
taking  hold  of  the  hands,  but  for  this  purpose  elastic  cords  or  straps 
answer  well,  as  the  weight  of  the  body  makes  the  pull  strongest  at  its 
termination.  Other  movements,  passive  and  resistive,  may  be  devised 
to  meet  the  indication  of  individual  cases,  and,  of  course,  it  will  not  be 
forgotten  that  active  or  voluntary  movements  may  be  turned  to  good 
account — ^with  special  modification — as  remedial  agents. 


CHAPTER  XXXVIII 

ELECTROTHERAPY;  X-RAY  THERAPY;  RADIUM 

Historic. — The  first  application  of  electricity  to  medicine  was 
made  during  the  early  part  of  the  eighteenth  century.  Static  electricity 
was  the  only  form  then  known.  Its  use  was  entirely  empirical,  and 
appears  to  have  been  suggested  by  observations  of  its  effect  upon  persons 
who  took  electric  shocks  to  gratify  curiosity.  De  Haen,  of  Vienna,  w-as 
the  first  to  make  extensive  employment  of  electricity  as  a  therapeutic 
agent,^  publishing  his  observations  in  1756,  although  others  had  pre- 
viously reported  isolated  cases.  In  1758  Benjamin  Franklin  introduced 
electrotherapy  into  .America,-  treating  a  numlDer  of  paralytics  without 
much  success.  Another  well-known  layman  who  was  interested  in 
this  subject  about  the  same  time  was  John  Wesley,  who,  in  1759,  wrote 
a  treatise  on  it.^ 

The  use  of  electricity  extended  and  soon  became  wide-spread.  The 
number  of  patients  who  were  treated  by  it  was  prodigious,  and  the  re- 
ported cures  were  indeed  miraculous.  After  the  first  misguided  and 
exaggerated  enthusiasm  had  subsided,  investigations  by  leading  physicians 
threw  discredit  upon  the  therapeutic  value  of  electricity,  and  its  use  was- 
for  a  time  relegated  to  quacks  and  imposters.  A  more  rational  view 
soon  prevailed,  however.  Writing  in  1780,  Cavallo*  says:  "But  at 
prefent  a  much  better  acquaintance  with  the  fcience  of  electricity  than 
philofophers  had  about  thirty  or  forty  years  ago,  has  pointed  out  the 
real  effects  of  that  power  upon  the  human  body  in  various  circum- 
ftances,  and  has  fhewn  how  far  w^e  may  confide  in  it;  eftablifhing, 
upon  indifputable  facts,  that  the  poAver  of  electricity  is  neither  that 
admirable  panacea,  as  it  was  confidered  by  fome  fanatical  and  interefted 
perfons,  nor  fo  ufelefs  on  apphcation  as  others  have  afferted;  but  tliat 
when  properly  managed,  it  is  an  harmleis  remedy,  which  fometimes  in- 
ftantaneoufly  removes  divers  complaints,  generally  relieves,  and  often 
perfectly  cures  various  diforders." 

^  Beard  and  Rockwell,  Medical  and  Surgical  Electricity,  New  York,  189 1,  eighth 
edition,  200. 

^  Kassabian,  Electro-therapeutics  and  Rontgen  Rays,  Phila.  and  London,  1907,  31. 

3  John  Wesley,  The  Desideration:  or  Electricity  made  Plain  and  Useful  by  a  Lovel 
of  Mankind  and  of  Common  Sense,  1759. 

*  Cavallo,  An  Essay  on  the  Theory  and  Practice  of  Medical  Electricity,  London,  178a 

335 


336  electrotherapy;  a;-RAY  therapy;  radium 

At  first  very  strong  shocks  were  given,  but  it  was  soon  discovered 
that  these  were  no  more  effective  than  weaker  ones  and  were  even  pro- 
ductive of  harm.  Electricity  was  tried  in  almost  every  conceivable 
medical  or  surgical  condition,  but  its  field  of  application  soon  became 
fairly  clearly  defined,  at  least  among  the  more  enlightened  members 
of  the  profession,  and,  except  that  we  now  no  longer  use  static  elec- 
tricity upon  abscesses  or  in  tonsillitis,  it  has  not  changed  greatly  up  to 
the  present. 

With  the  discovery  of  animal  electricity  by  Galvani,  in  1790,  and 
the  invention  of  the  Voltaic  pile,  ten  years  later,  the  continuous  current 
began  to  be  used  in  therapeutics,  and,  after  the  work  of  Faraday  in  183 1- 
1832,  the  induced  current  also  received  wide  employment  in  medicine. 
These  were,  however,  used  empirically  and  indiscriminately  until 
Duchenne,  in  1850,  laid  down  the  principles  for  the  scientific  use  of 
local  faradism,  and  it  was  not  until  even  later  that  Remak,  of  Berlin, 
applied  the  same  principles  to  the  use  of  the  galvanic  current. 

Steady  progress  from  this  time  on  was  made  in  the  rational  applica- 
tion of  electricity,  but  with  no  great  impetus  until  the  discovery  of  the 
Rontgen  rays  in  1895,  ^^^  of  light  therapy  by  Finsen  two  years  pre- 
viously, ushered  in  an  era  of  rapid  development,  to  which  the  recent 
discovery  of  the  therapeutic  possibilities  of  radium  has  added  an  im- 
portant factor. 

In  the  after-treatment  of  surgical  conditions  electricity  in  its  various 
forms  has  as  definite  and  useful  a  place  as  in  general  medicine.  It  is 
not  a  panacea,  but  when  intelligently  used  to  meet  definite  indications, 
it  is  invaluable.  These  indications,  the  form  of  electricity  to  be  used, 
and  the  technique  of  its  applications,  will  be  briefly  set  forth  in  the  fol- 
lowing pages: 

INDICATIONS 

Relief  of  Pain. — Pain  may  be  divided  technically  into — (a)  Habit 
pain;  (b)  pain  due  to  congestion  of  stasis;  and  (c)  pain  due  to  cicatricial 
pressure. 

(a)  Habit  Pain. — It  is  a  well-known  fact  that  frequently  pain  that 
has  existed  for  some  time  prior  to  an  operation  will  persist  to  almost 
the  same  degree  postoperatively.  Where  we  find  no  cause  for  such 
pain  we  are  forced  to  call  it  a  habit  pain,  though  with  refinements  in 
methods  of  diagnosis  the  number  of  so-called  habit  pains  is  constantly 
growing  less.  In  a  true  habit  pain  some  mechanic  or  electric  method 
of  treatment  offers  the  quickest  possibility  of  relief.  Where  we  can 
determine  the  nerve  supply  involved,  vibration,  applied  to  the  appro- 


congestion;  pain  337 

priate  nerve-center  in  the  spine  until  inhibition  is  produced,  is  the  first 
choice.  This  treatment  should  be  given  for  ten  to  tw'enty  minutes, 
and  should  be  repeated  often  enough  to  "bridge  the  pain";  that  is, 
so  as  to  render  the  patient  free  from  pain,  which  may  mean  daily  treat- 
ments, or  treatments  every  second,  third,  or  fourth  days.  (See  Vibra- 
tion.) 

Other  cases  may  be  relieved  by  the  incandescent  or  the  arc  light; 
the  superficial  hyperemia  which  is  produced  will  cause  analgesia  of  the 
part,  plus  the  effects  of  increased  nutrition.  If  the  blue  light  be  used, 
there  is  produced  a  local  anesthesia  of  the  nerve-endings  as  well  as  local 
ischemia,  due  to  stimulation  of  the  vasoconstrictors.  (For  technique, 
see  Light  Therapy.) 

At  times  the  positively  connected  sponge  of  the  direct  (galvanic) 
current,  saturated  with  a  20  per  cent,  solution  of  cocain  hydrochlorid, 
placed  directly  over  the  painful  areas,  the  negative  pole  being  placed 
indifferently,  using  large,  well-moistened  pads  with  a  current  strength 
of  from  5  to  50  ma.,  will  be  found  of  advantage.  The  main  object  of 
treatment  is  to  keep  the  pain  under  control,  so  that  the  chain  of  habit 
may  be  broken. 

(b)  Pain  Due  to  Congestion  or  Stasis. — Frequently,  for  example  after 
a  resection  of  an  ovary,  there  remain  behind  large  and  varicosed  blood- 
vessels, which,  distributing  the  same  supply  of  blood  to  the  part  as 
before  operation,  will  cause  the  same  pain  and  feeling  of  weight  to 
persist.  Here  the  static  wave  current,  by  producing  deep-seated  mus- 
cular contractions,  by  its  apparent  power  of  restoring  muscular  tone, 
and  by  its  analgesic  effect  on  nerve-endings,  is  the  treatment  par  excel- 
lence. A  metal  plate  of  block  tin,  large  enough  to  cover  the  sacral  and 
lumbar  portion  of  the  back,  should  be  connected  by  a  wire  to  the  positive 
pole  of  a  static  machine;  similarly,  another  strip  of  metal  sufficiently 
large  should  be  placed  over  the  abdomen  and  this  plate  also  connected 
to  the  positive  pole.  The  further  technique  is  given  under  the  head  of 
the  static  wave  current.  Treatments  should  be  from  fifteen  to  thirty 
minutes  every  other  day. 

At  times,  though  painful,  the  indirect  -static  spark,  by  producing 
deep-seated  muscular  contractions,  will  give  the  same  effect.  The 
sparking  should  be  applied  over  the  area  of  pain,  single  not  multiple 
sparks  being  employed,  and  continued  until  all  pain  is  gone.  At  first 
daily  treatments  should  be  used. 

(c)  Pain  Due  to  Cicatricial  Pressure. — Those  who  have  seen  even  a 
keloid  disappear  under  the  Rontgen  rays  know  what  great  power  of 
absorbing  scar  tissue  the  rays  have.     A  tube  which  shows  the  bone  of 


338  electrotherapy;  x-ray  therapy;  radium 

the  hand  black  is  the  best  one  to  use,  and  it  should  be  employed  for 
eight  minutes  at  a  distance  of  10  to  12  in.  from  the  skin,  measuring  from 
the  central  anode  of  the  tube.  For  the  first  four  treatments  every  third 
day  will  be  enough,  and  then  every  five  to  eight  days,  until  the  pain 
has  ceased  or  a  slight  dermatitis  has  developed. 

A  hard,  constricting  cicatrix  may  be  replaced  by  a  soft,  pliable  scar 
by  means  of  metallic  electrolysis.  The  technique  is— connect  with  the 
negative  binding  post  of  the  galvanic  plate  a  needle,  or  needles,  inserted 
J  in.  into  the  periphery  of  the  scar.  A  sponge  electrode  the  size  of  the 
hand  is  bound  anywhere  on  the  patient,  and  a  current  of  2  to  15  ma.  is 
allowed  to  flow  until  the  tissue  around  the  needles  is  completely  bleached. 
This  requires  from  one  to  two  minutes,  and  is  to  be  repeated  until  the 
scar  is  completely  surrounded  by  a  ring  of  these  bleached  marks.  Co- 
cain  cataphoresis  will  render  the  operation  nearly  painless.  No  anti- 
septic or  cerate  dressing  should  be  used  afterward.  Repeat  in  a  week 
if  necessary. 

Atrophy  of  the  Musculature  Due  to  Disuse.— This  is  one 
of  the  most  important  indications  for  postoperative  electrotherapy. 
Here  the  induced  current  (faradic)  should  be  employed,  using  the  rapid 
interruption,  and  current  strength  enough  to  produce  gentle  but  decided 
contractions  of  the  muscle  or  muscles  involved.  One  pad  should  be 
placed  over  the  spine  while  the  other  should  be  gently  stroked  over 
the  muscles  for  ten  to  fifteen  minutes  every  other  day.  This  may  be 
followed  by  massage  or  vibratory  stimulation,  using  the  large  round 
rubber  vibratrode  for  five  to  ten  minutes. 

Nerve  injuries  may  be  divided  into  three  classes:  (a)  Pressure 
neuritis;    (b)  operative  injury  to  nerve;   and  (c)  severed  nerve. 

(a)  Pressure  neuritis  is  due  to  pressure  sustained  by  a  nerve  during 
a  prolonged  operation.  If  no  reaction  of  degeneration  be  present,  the 
resulting  paralysis  may  be  treated  similarly  to  atrophy  of  the  muscula- 
ture due  to  disuse.  If  there  be  a  diminished  reaction  to  the  induced 
current  (faradic)  and  no  pain  is  present,  high-tension  faradism  may  be 
used  for  five  minutes,  followed  by  interrupted  galvanism  (60  to  100 
interruptions  a  minute),  the  negative  sponge  being  stroked  over  the 
affected  muscles  while  the  positive  is  firmly  affixed  over  the  spine.  If 
pain  is  present,  the  positive  sponge  of  the  direct  current  (galvanic) 
should  be  gently  rubbed  over  the  nerve-trunk,  care  being  taken  not  to 
use  the  interrupter  nor  to  cau'se  muscular  contraction  by  breaking  the 
contact  of  the  sponge  with  the  skin.  If  the  pain  is'  excessive,  the  positive 
sponge  may  be  saturated  with  a  20  per  cent,  solution  of  cocain  or  the 
indirect  static  spark  employed  for  five  minutes. 


ANKYLOSIS  339 

If  a  complete  reaction  of  degeneration  be  present,  the  positive  sponge 
should  be  used  as  above,  without  interruption  if  pain  is  present  and 
with  interruption  if  there  is  no  pain.  A  current  of  2  to  20  ma.  for  ten 
to  thirty  minutes,  repeated  every  other  day,  is  sufficient.  If  the  pain  is 
severe,  the  positive  sponge  may  be  bound  on  the  part,  as  the  mere  act  of 
stroking  may  cause  increased  pain,  and,  for  this  reason,  massage  or 
vibratory  stimulation,  if  used  at  all,  should  be  tried  guardedly.  The 
high-frequency  monopolar  vacuum  tube  (exhausted  to  a  blue  vacuum) 
and  light,  incandescent  or  arc,  are  at  times  also  useful  in  palliation  of 
pain. 

(b)  Operative  injury  to  ?ierves  should  be  treated  as  above,  the  treat- 
ment varying  with  the  amount  of  the  reaction  of  degeneration  and  the 
pain  present. 

(c)  Severed  Nerves.— li  the  cut  ends  are  nearly  approximate,  union 
may  take  place,  and  they  should  be  treated  as  a  complete  reaction  of 
degeneration  with  pain.  If  the  approximation  is  not  present,  no  result 
will  be  obtained. 

Adhesions  and  Ankylosis. — This  subject  may  be  considered 
imder  the  headings:  {a)  Joints;  (6)  contractures  of  fingers  or  toes;  and 
(c)  adhesions  elsewhere  in  the  body. 

(a)  Joints. — i\fter  operative  work  on  the  joints  pain  and  limitation 
of  motion,  due  to  adhesions  or  ankylosis,  may  be  a  prominent  feature. 
This  may  ordinarily  be  speedily  relieved  by  the  following  method: 

First,  baking  the  joint  with  superheated  dry  air,  which,  inducing 
an  active  hyperemia,  relieves  the  pain  and  causes  increased  absorption 
of  exudates  (for  Technique,  see  Superheated  Dry  Air),  followed  by 
stretching  of  the  joint  by  massage  and  manual  manipulation,  or  vibratory 
stimulation  while  the  joint  is  on  the  stretch,  using  the  ball  vibratrode 
and  as  great  an  excursion  of  stroke  as  the  patient  can  tolerate.  If  there 
is  increased  pain  after  this  procedure,  the  indirect  static  spark,  the  static 
wave  current  (wrapping  a  sheet  of  foil  around  the  joint),  or  the  monopolar 
high-frequency  vacuum  tube  may  be  used  from  ten  to  fifteen  minutes. 
Treatment  should  be  repeated  every  third  to  fifth  day  until  relatively 
free  and  painless  motion  is  obtained. 

(b)  Contractures  of  Fingers  or  Toes. — A  saturated  solution  of  sodium 
chlorid  on  the  negative  sponge  of  the  direct  current  (galvanic)  should 
be  placed  over  the  contractures,  with  the  opposite  side  resting  on  the 
positive  sponge  and  a  current  of  10  to  30  ma.  driven  through  the  part 
for  fifteen  to  twenty-five  minutes,  the  object  being  to  soften  the  tissues 
through  the  resolvent  effect  of  the  chlorin  atoms  or  ions  liberated  by 
the.  negative  pole  saturated  with  sodium  chlorid.     Massage  and  stretch- 


340  electrotherapy;  a;-RAY  therapy;  radium 

ing  by  means  of  the  vibrator  should  follow.  Repeat  every  other  day 
unless  the  skin  becomes  too  tender. 

(c)  For  adhesions  in  the  abdomen  there  is  a  slight  chance,  by  the 
use  of  the  rv-ray  (remembering  the  possibility  of  producing  sterility), 
by  the  sodium  chlorid  cataphoresis  described  above,  or  the  gentle  vibra- 
tion, to  relieve  the  condition,  though  ordinarily  adhesions  sufficient  to 
cause  much  in  the  way  of  symptoms  call  for  operative  interference. 

I/Ow  Vital  States. — In  addition  to  proper  hygiene  and  diet, 
and  tonic  treatment  where  indicated,  static  insulation,  the  static  wave 
current,  or  the  arc  light  may  be  used  every  other  day  for  fifteen  to  thirty 
minutes  to  increase  the  hemoglobin  and  number  of  red  corpuscles. 
For  exhaustion  the  high-frequency  monopolar  vacuum  tube,  or  the  static 
wave  current  with  the  metal  electrode  down  the  spine,  is  useful,  (See 
Postoperative  Neurasthenia.) 

Postoperative  Neurasthenia. — In  this  condition  the  treat- 
ment is  general  and  symptomatic.  If  there  is  any  toxic  basis  for  nervous 
exhaustion  autocondensation,  by  its  apparent  stimulation  of  the  sympa- 
thetic nerve  system,  will  cause  increased  elimination  (as  may  be  proved 
by  urinary  examination),  and  will  engender  a  feeling  of  well  being. 
Exhaustion  on  the  slightest  muscular  exertion  will  call  for  general 
faradization  (which  see)  and  general  vibratory  stimulation.  For  head- 
ache and  sense  of  pressure  in  the  head  the  static  wave  current  with  a 
metal  strip  along  the  spine  for  twenty  minutes,  followed  by  a  positive 
static  breeze  for  ten  minutes,  will  afford  much  relief.  For  a  tender, 
irritable  spine,  the  arc  light,  the  static  wave  current,  the  high-frequency 
monopolar  vacuum  tube,  or  a  long  sponge  connected  with  the  positive 
side  of  the  galvanic  plate,  the  negative  over  the  abdomen,  lo  to  30  ma. 
for  twenty  minutes,  may  be  employed. 

For  the  various  paresthesias  the  faradic  wire-brush  or  the  high- 
frequency  monopolar  vacuum  will  be  indicated.  For  insomnia  use  the 
static  wave  current,  the  positive  head  breeze,  or  the  incandescent  or 
arc  light  over  the  spine.  For  mental  exhaustion  employ  the  high- 
frequency  monopolar  vacuum  tube  along  the  spine  and  over  the  head  for 
fifteen  minutes  with  a  current  strength  as  great  as  the  patient  can  toler- 
ate, followed  by  the  positive  static  head  breeze  for  ten  minutes.  For 
fermentation  use  the  static  wave  current  with  a  large  metal  plate  over 
the  abdomen,  repeated  every  second  or  third  day  for  twenty  to  thirty 
minutes. 

High  Blood-pressure  and  Sclerotic  Changes  in  the 
Arteries. — Where  there  is  a  high  blood-pressure  and  there  is  no  chronic 
interstitial  nephritis,  the  blood-pressure  may  be  steadily  and  apparently 


^-RAY    FOR   CANCER  34 I 

fairly  permanently  reduced  by  autocondensation  with  200  to  400  ma., 
flowing  for  twenty  to  thirty  minutes.  The  treatments  should  be  repeated 
every  third  day  until  a  normal  pressure  has  been  reached.  Cases  so 
treated  have  remained  normal  for  over  two  years.  The  more  moderately 
increased  pressures  may  be  reduced  by  applying  the  high-frequency 
monopolar  vacuum  tube  over  the  spine  and  the  solar  plexus  for  ten  to 
fifteen  minutes. 

This  reduction  in  pressure  is  apparently  due  to  the  stimulation  of 
the  sympathetic  nervous  system.  The  immediate  drop  is  due  to  stimu- 
lation of  the  vasomotors,  and  the  permanency  to  the  increased  elimina- 
tion due  to  the  sympathetic  stimulation. 

After  Operations  for  Malignant  Disease. — Whatever  one's 
opinions  may  be  regarding  the  use  of  the  Rontgen  ray  before  resorting 
to  operation  in  malignant  disease,  there  can  be  little  doubt  that  it  forms 
an  often  valuable  and  effective  means  of  dealing  with  recurrent  growths 
and  of  preventing  recurrences.  At  the  symposium  upon  the  therapeutic 
value  of  the  Rontgen  ray  in  surgery,  held  at  the  meeting  of  the  Amer- 
ican Surgical  Association  in  1902,^  its  postoperative  use  was  advocated 
by  Wilhams,  Be  van,  Coley,  Rodman,  Pf  abler,  and  Johnson  for  both 
these  indications. 

Holding  2  has  analyzed  148  cases  from  the  literature  of  inoperable 
or  recurrent  malignant  disease  treated  by  the  Rontgen  rays  and  found 
that  32  per  cent,  were  "apparently  cured"  (meaning  complete  disap- 
pearance of  the  growth,  but  without  five  years  having  elapsed),  58  per 
cent,  were  improved,  and  only  10  per  cent,  not  benefited.  Of  the 
entire  number,  16  were  recurrent  carcinomata,  and  of  these,  in  13  the 
growth  disappeared  entirely,  and  in  the  remaining  3  marked  improve- 
ment was  noted. 

Although  the  widest  employment  of  the  rays  has  been  in  carcino- 
mata, they  have  also  been  well  tried  out  in  sarcomata.  Coley,^  whose 
experience  with  the  treatment  of  sarcomata,  both  by  the  mixed  toxins 
of  the  streptococcus  and  bacillus  prodigiosus  and  the  Rontgen  rays, 
has  been  extensive,  states  that  the  rays  have  caused  disappearance  of 
the  disease  in  some  cases  where  the  toxins  alone  have  failed,  but  that  in 
each  of  these,  however,  the  growth  soon  returned,  whereas  a  consider- 
able number  cured  by  the  toxins  remained  well  after  a  period  of  years. 
He  states  that  the  poorest  results  of  the  Rontgen  rays  have  been  in  the 
spindle-cell  sarcoma,  in  which  variety  the  best  results  are  obtained  by  the 
toxins.     Therefore,  he  ad\-ocates  the  combined  use  of  these  two  agents 

^  Trans.  Amer.  Surg.  Assoc,  1903,  xxi,  208. 

^  Albany  Med.  Ann.,  1903,  xxiv,  94.  ^  Ibid.,  215. 


342  electrotherapy;  x-ray  therapy;  radium 

in  the  hope  that  the  rays  may  accomphsh  what  is  left  undone  by  the 
toxins. 

In  tuberculous  lymph-nodes  the  Rontgen  ray  has  been  apparently 
of  decided  therapeutic  value  in  some  cases  when  used  in  conjunction 
with  the  general  measures  for  the  treatment  of  tuberculosis.  Sinuses 
have  been  reported  to  heal  rapidly  under  its  use. 

Keloids  frequently  disappear  with  rapidity  under  Rontgen-ray  treat- 
ments, leaving  a  fine  white  line,  soft  and  pliable,  which  in  the  course  of 
time  closely  resembles  the  surrounding  skin. 

ELECTROTHERAPEUTIC  TECHNIQUE 

Static  electricity  is  exhibited  in  three  forms:  (a)  Wave  cur- 
rent,  {h)  Spark,   (c)  Head  crown  breeze. 

{a)  Wave  Current. — -Patient  on  insulated  platform;  spark  balls  of 
machine  together;  negative  pole  grounded;  positive  pole  connected 
by  a  wire  to  tin-foil  firmly  placed  against  the  bare  skin  of  the  part  to  be 
treated  (if  around  a  joint,  bind  with  bandage) ;  machine  started  at  not 
more  than  200  revolutions  a  minute,  and  spark  balls  gradually  pulled 
out  to  the  point,  just  short  of  causing  pain  to  the  patient.  Treatments 
every  second  or  third  day;  duration,  fifteen  to  thirty  minutes.  Any 
prickling  sensation  means  that  the  foil  is  not  in  close  approximation  to 
the  skin  and  may  be  overcome  by  having  the  patient  press  that  point 
against  the  skin. 

(6)  Spark. — Patient  on  insulated  platform;  spark  balls  of  the  machine 
wide  apart;  negative  pole  grounded;  positive  pole  connected  by  metal 
rod  to  platform;  the  other  ground  wire  (connected  to  gas-pipe  or  water- 
pipe)  connected  to  ball  electrode,  which  is  brought  near  enough  to  patient 
to  cause  a  spark  to  leap  forth.  Single  sparks  (as  multiple  sparks  are 
poorly  tolerated)  should  be  given  over  as  wide  an  area  as  possible  until 
pain  is  relieved.     Treatments  repeated  on  any  return  of  pain. 

(c)  Head  Crown  Breeze. — Patient  seated  in  a  comfortable  chair  on 
an  insulated  platform;  negative  pole  grounded;  positive  pole  connected 
with  metal  rod  to  platform  or  held  by  patient,  the  other  ground  con- 
nected by  wire  to  metal  head  crown,  which  should  be  suspended  at  such 
a  distance  above  patient's  head  that  he  feels  a  strong  breeze  with  just  a 
suggestion  of  tingle.  Treatments  repeated  as  often  as  needed  to  relieve 
condition.     Time  of  treatment,  ten  to  thirty  minutes. 

High  Frequency. — ia)  Autocondensation.  (h)  Low  vacuum  tubes. 

(a)  Autocondensation. — To  one  pole  of  the  d'Arsonval  current  of 
the  American  type  of  high-frequency  machine  a  long  metal  rod  is  con- 


GALVANIC    CURRENT 


343 


nected,  which  is  held  in  the  hands  of  the  patient.  The  other  pole  is 
connected  with  a  metal  plate,  which  is  insulated  from  the  patient  by 
two  sheets  of  rubber  and  a  felt  cushion  or  mattress  at  least  3  in.  in  thick- 
ness. The  best  result  is  obtained  by  having  the  patient  reclining  on 
a  rattan  couch  free  from  metal  nails  or  screws.  With  a  hot-wire  meter 
in  the  circuit,  from  200  to  400  ma.  of  current  is  turned  on  for  ten  to 
t^venty  minutes.     Repeated  every  third  day. 

(b)  Loiu  Vacuum  Tubes. — Tubes  exhausted  to  a  blue  vacuum  are 
best  for  relief  of  pain.  Ordinarily  they  are  connected  by  the  monopolar 
method  and  are  applied  over  the  bare  skin,  as  thereby  a  greater  degree 
of  current  can  be  tolerated  by  the  patient.  If  a  strong  counterirrit.ant 
effect  is  desired,  they  can  be  applied  through  the  clothing.  As  strong  a 
current  should  be  used  as  the  patient  will  stand,  unless  the  erythema 
of  the  skin  becomes  too  marked.  The  local  action  is  decreased  nerve 
irritability,  followed  by  local  anesthesia,  increased  action  of  the  sw^eat- 
glands,  hyperemia  of  the  skin,  increased  temperature,  and  liberation  of 
free  ozone  in  the  tissues.  Duration  of  treatment,  five  to  fifteen  minutes; 
frequency,  every  second,  third,  or  fifth  day.  If  the  vacuum  tube  sticks 
to  the  skin,  a  little  talcum  powder  will  allow  it  to  be  moved  freely  over 
the  surface.  If  the  patient  complains  of  pricking  or  tingling  afterward, 
this  may  be  relieved  by  the  application  of  cold  cream. 

Direct  Current  (Galvanic). — With  the  direct  current  polarity 
is  all  important.  As  large  pads  as  possible  should  be  used,  well  moistened, 
as  thereby  a  greater  amount  of  current  can  be  employed  with  less  dis- 
comfort to  the  patient.  The  treatment  in  general  is,  wherever  there  is 
pain  or  complete  reaction  of  degeneration,  use  the  positive  pole,  while 
if  there  are  no  pain  and  no  polar  inversion,  the  negative  pole  is  indicated. 
For  the  introduction  of  medicinal  solutions  into  the  tissues  we  find  that  the 
acids  and  acid  radicles,  being  electronegative,  should  be  placed  on  the 
negative  pole,  while  the  bases  and  alkaloids,  being  electropositive,  should 
be  placed  on  the  positive  pole;  thus,  for  example,  if  we  wish  to  introduce 
cocain  hydrochlorid,  the  cocain  would  be  placed  on  the  positive  pole; 
if  we  wish  to  introduce  the  chlorin  atoms  of  sodium  chlorid,  or  the  iodin 
atoms  of  potassium  iodid,  the  negative  pole  should  be  employed.  If 
there  are  no  pain  and  no  reaction  of  degeneration  in  the  paralyzed  muscle, 
the  faradic  current  may  be  used,  while  if  there  are  a  partial  reaction  of 
degeneration  and  no  pain,  an  interrupted  galvanic,  60  to  100  interrup- 
tions a  minute,  is  best. 

The  direct  current  has  a  decidedly  nutritional  effect  on  the  nerve 
tissues,  and  hence  should  be  employed  where  we  desire  increased  nerve 
nutrition  or  stimulation. 


344  electrotherapy;  x-ray  therapy;  radium 

I/ight  Therapy. — For  therapeutic  purposes  two  forms  are  ordi- 
narily used :   (a)  Incandescent  light  and  (b)  arc  light. 

(a)  Incandescent  Light. — This  may  consist  of  a  cluster  of  lights 
under  a  polished  metal  reflector  or  a  single  light  of  200  to  500  candle 
power.  The  main  effect  from  either  is  the  heat-production  and  stimu- 
lation of  the  tissues  by  the  radiant  light-rays.  The  heat  and  the  resulting 
active  hyperemia  are  the  main  factors  to  be  considered.  The  technique 
is  as  follows:  The  exposure  should  always  be  made  over  the  bare  skin. 
The  patient  is  best  treated  in  a  recumbent  position,  the  light  being 
suspended  overhead.  The  light  should  be  gradually  brought  down 
nearer  the  surface  until  tolerance  of  a  considerable  degree  of  heat  has 
been  established.  Swinging  the  light  from  side  to  side  will  prevent  any 
burning  from  focusing  the  light-rays  on  one  point  for  too  long  a  time. 
Stroking  the  flesh  with  the  hand  will  achieve  the  same  result.  Treat- 
ment should  be  continued  until  the  pain  has  ceased  or  until  the  patient's 
temperature  has  reached  over  100°  F.,  or  until  the  pulse-rate  has  in- 
creased to  1 20.  The  treatment  should  be  repeated  as  frequently  as  neces- 
sary to  relieve  the  symptoms,  whether  it  be  every  day  or  once  a  week. 

(b)  Arc  Light. — The  arc  light  has  a  spectrum  analogous  to  that  of 
the  sun,  and  is  especially  rich  in  ultra-violet  rays.  Except  for  the  cost 
of  operation  and  the  closer  personal  attention  required,  it  is  far  superior 
in  every  way  to  the  incandescent  light.     The  technique  is  as  follows: 

(i)  The  Whole  Arc  Light. — Exposure  made  on  the  bare  skin;  light 
at  a  distance  of  18  to  36  in.,  depending  on  the  tolerance  of  the  patient 
to  the  heat;  time  of  treatment,  five  to  fifteen  minutes  on  each  part 
exposed;  maximum  of  treatment,  twenty-five  minutes.  Applications 
from  every  day  to  over  a  week,  dependent  on  pain. 

(2)  Blue  Screen. — Here  a  screen  of  blue  glass  is  interposed  between 
the  light  and  patient  and  the  technique  is  similar,  only  we  do  not  need 
any  great  amount  of  heat,  as  the  effect  we  wish  to  produce  is  a  local 
ischemia  and  anesthesia.  The  blue  screen  has  a  strong  sedative  effect, 
and  will  produce  a  local  anesthesia  sufficiently  strong  to  allow  one  to  open 
small  furuncles  painlessly.  The  vasoconstrictors  are  stimulated,  and 
consequently  a  more  vigorous  circulation  is  established  through  any 
region  where  stasis  has  been  present.  A  striking  example  of  its  anesthetic 
properties  is  in  orchitis,  when,  after  fifteen  minutes'  exposure,  examina- 
tion may  be  made  without  pain.  Granulating  surfaces  which  are 
indolent  and  painful  heal  rapidly  and  with  a  great  decrease  in  pain. 

(3)  Red  Screen. — Technique  similar  to  that  of  blue  screen.  The 
red  screen  has  strong  stimulating  powers  and  acts  as  a  direct  nerve- 
irritant  and  stimulant. 


VIBRATION  345 

Superheated  Dry  Air. — The  source  of  heat  may  be  alcohol, 
gas,  or  gasoline,  and  a  special  baker  is  provided  for  the  different  joints. 
The  main  object  is  to  raise  the  temperature  to  from  350°  to  450°,  with 
its  consequent  very  active  hyperemia  and  dilatation  of  the  superficial 
blood-vessels.  This  intense  heat  and  increased  circulatory  activity  is 
accredited  with  certain  bactericidal  powers  also. 

The  technique  is  as  follows:  The  joint  should  be  entirely  bare  and 
then  wrapped  with  several  thicknesses  of  Turkish  toweling,  and  in  this 
condition  placed  inside  the  baker.  Any  point  which  may  become  ischemic 
from  pressure  should  have  an  extra  fold  of  Turkish  toweling,  so  as  not 
to  become  burned.  The  ends  of  the  baker  are  well  covered  and  the 
heat  gradually  increased  until  400°  or  450°  is  obtained,  or  to  the  point 
of  tolerance  of  the  patient.  This  should  be  continued  from  fifteen  to 
thirty  minutes.  As  in  the  incandescent  light,  the  pulse,  temperature, 
and  general  feelings  of  the  patient  are  the  guide  as  to  the  length  of  treat- 
ment, and  arteriosclerotics  should  be  watched  carefully.  This  may  be 
repeated  every  third  or  fifth  day,  and,  after  every  treatment,  if  there  is 
any  ankylosed  condition  in  the  joint,  it  should  be  stretched  by  means  of 
the  vibrator  or  by  massage  with  manipulations. 

Vibration. — For  successful  vibratory  treatments  a  vibrator  having 
either  the  lateral  or  gyratory  stroke  is  essential.  The  percussive 
stroke  is  of  very  limited  value.  We  can  hope  to  accomplish  one  of  t\vo 
main  objects  with  vibration — either  stimulation  or  inhibition.  The 
latter  is  the  result  of  excessive  stimulation.  In  all  vibratory  treatments 
it  is  desirable  to  apply  the  vibratrode  directly  to  the  bare  skin  and  to 
have  the  patient  recumbent,  as  thereby  much  better  relaxation  is  secured. 
For  general  vibratory  stimulation  the  patient  should  remove  all  tightly 
fitted  clothing,  and  the  remaining  clothing  should  be  so  arranged  that  it 
will  be  easy  to  get  at  the  various  parts  of  the  body.  It  is  better  to  have 
a  loose  gown  which  ties  up  the  back  than  to  use  a  sheet.  For  general 
stimulation  the  patient  should  lie  on  the  table,  back  up,  arms  hanging 
down  at  the  sides,  head  turned  to  one  side.  Now  bare  the  back,  and 
apply  vibration  with  a  medium  stroke  and  as  much  pressure  as  the 
patient  can  stand,  between  the  transverse  processes  of  the  vertebras, 
for  fifteen  to  thirty  seconds  at  each  point,  using  the  ball  vibratrode. 
Then,  with  the  flat  brush  vibratrode,  go  over  the  arms  and  legs,  back 
muscles,  chest,  and  the  abdomen.  If  constipation  is  a  feature,  con- 
tifiue  the  vibration  over  the  course  of  the  colon  and  over  the  epigastrium 
to  stimulate  the  solar  plexus,  and  longitudinally  across  the  abdomen 
to  stimulate  the  small  intestine.  For  inhibition  the  vibration  should 
be  applied  for  a  longer  period — one  to  three  minutes — over  the  appro- 


346  electrotherapy;  o^-ray  therapy;  radium 

priate  nerve  centers  in  the  spine.  Treatments  should  be  repeated  daily  if 
necessary.  Similarly,  stimulation  or  inhibition  may  be  applied  locally 
in  th€  treatment  of  strains,  sprains,  or  contusions,  and,  as  already 
described  under  Adhesions,  for  postoperative  joint  conditions. 

Induced  Current  (Faradic). — This  is  useful  for  muscle  stim- 
ulation, and,  as  we  saw  when  discussing  the  direct  current,  it  may 
be  used  to  prevent  further  atrophy,  provided  there  is  no  reaction  of 
degeneration.  It  has  been  considered  that  its  polarity  was  theoretic 
only,  but  some  experiments  recently  made  seem  to  show  that  there  is 
considerable  polar  action.  It  should  be  used  by  placing  one  sponge 
indifferently  and  stroking  the  affected  muscles  with  the  other.  One 
form  of  treatment  of  great  value,  but  unfortunately  little  used,  is  the 
so-called  general  faradization.  Its  technique  is  to  have  the  patient 
thoroughly  undressed,  with  both  bare  feet  resting  on  a  copper  plate 
which  has  been  wet  with  a  little  warm  water,  and  with  a  sponge  con- 
nected with  the  other  pole  of  the  faradic  coil  to  apply  the  current  over 
all  parts  of  the  body,  paying  special  attention  to  the  top  of  the  head, 
the  ciliospinal  center  (seventh  cervical),  and  the  solar  plexus.  The 
object  is  to  put  all  parts  of  the  body  under  the  effect  of  the  current. 
The  spine  should  be.  treated  for  five  minutes,  the  muscles  of  the  back 
for  three,  each  extremity  for  two,  the  abdomen  for  four,  and  the  chest 
muscles  for  two.  Treatments  should  be  repeated  every  third  day  and 
sufficient  current  strength  used  to  cause  agreeable  muscular  contractions. 

The  Rontgfen  Ray. — Since  any  surgeon  about  to  purchase  an 
x-rdy  outfit  would  naturally  consult  one  of  the  several  text-books  de- 
voted to  this  subject,  it  does  not  fall  within  the  scope  of  this  work  to 
discuss  such  apparatus.  The  general  principles  of  the  use  of  the  x-rays 
in  surgical  after-treatment  we  shall,  however,  describe  briefly.  The 
method  of  procedure  inaugurated  by  Dr.  Williams,  at  the  Boston  City 
Hospital,  is  as  follows:  After  operation  for  malignant  disease  the  treat- 
ment by  the  Rontgen  rays  is  commenced  as  soon  as  the  patient  can  be 
transported  to  the  rv-ray  department  (i.  e.,  in  from  two  to  seven  days). 
The  scar  and  the  region  of  the  neighboring  glands  are  exposed  to  the 
rays  for  from  five  minutes  to  one-half  hour,  depending  upon  the  size 
of  the  area  to  be  exposed — the  larger  the  surface,  the  longer  the  exposure. 
The  rays  are  transmitted  through  an  aluminum  screen.  The  distance 
of  the  patient  from  the  tube  is  determined  by  means  of  Dr.  Williams' 
fluorometer,  by  which  the  point  at  which  the  rays  are  of  greatest  strength 
is  found,  and  the  surface  to  be  exposed  is  placed  at  this  distance,  usually 
about  1 8  in.  from  the  tube.  Treatment  three  times  a  week  is  kept  up 
for  at  least  two  months.     If  at  the  end  of  this  time  there  is  no  sim  of 


RADIUM   FOR   CANCER  347 

recurrence,  it  is  discontinued,  but  the  patient  reports  once  a  month  for 
one  year  and  then  every  three  months  up  to  five  years  for  observation. 
At  the  slightest  sign  of  return  of  the  disease  treatment  is  reinstituted. 

When  a  recurrence  has  already  taken  place,  treatment  should  be 
commenced  at  once.  The  area  involved  is  exposed  for  a  short  time 
(five  minutes  or  longer)  and  the  reaction  is  noted.  This  reaction  con- 
sists in  swelling,  exudation,  crust  formation,  and  some  softening  of  the 
pathologic  tissue.  In  some  instances  there  is  only  a  slight  redness  of 
the  surface.  If  there  is  more  than  a  slight  reaction,  it  is  allowed  to 
subside  before  the  second  exposure  is  made,  and  the  duration  of  the  treat- 
ment is  shortened.  On  the  other  hand,  if  there  is  no  reaction,  or  only 
slight  reaction,  the  next  exposure  is  made  in  two  or  three  days,  and  its 
duration  increased.  In  this  way  the  frequency  and  length  of  the  treat- 
ments are  determined  in  each  individual  case.  Growths  will  usually 
begin  to  show  improvement  within  t^vo  weeks.  Treatment  is  con- 
tinued until  all  evidence  of  the  disease  has  disappeared  and  then  stopped, 
but  the  patient  is  kept  under  close  observation  and  treatment  reinstituted 
if  there  is  the  slightest  sign  suspicious  of  recurrence. 

Radium. — The  use  of  the  radiations  from  radium  salts  as  a  substi- 
tute for  the  rv-rays  was  first  suggested  by  Dr.  William  Rollins,  of  Boston.^ 
In  the  development  of  the  therapeutic  use  of  radium  Dr.  Francis  H. 
Williams  holds  the  leading  place.  The  action  is  exactly  similar  but 
much  superior  to  that  of  the  x-rays,  which,  where  available,  it  has  en- 
tirely supplanted  in  the  treatment  of  small,  easily  accessible  growths.  In 
growths  occupying  a  large  area  the  x-rays  alone,  or  in  combination 
with  radium,  are  indicated,  and  the  x-rays  alone  in  the  case  of  malignant 
disease  of  the  internal  organs.  The  general  principles  for  the  employ- 
ment of  the  x-rays  as  regards  indications  for,  reaction  from,  and  fre- 
quency of  exposure,  apply  also  to  radium. 

The  method  of  application  of  radium  is  the  following:  50  mg.  (a 
little  less  than  i  ^r.)  of  pure  radium  bromid  contained  in  a  capsule, 
covered  with  a  rubber  cot  for  sake  of  cleanliness,  at  the  end  of  a  handle 
at  least  i  ft.  long,  is  moved  about  close  to  the  surface  to  be  treated  for 
from  two  to  fifteen  minutes  according  to  the  size,  beginning  at  the  least 
affected  portion,  but  applied  longest  to  the  most  active  spot  of  disease. 
The  radium  must  be  kept  constantly  moving  and  not  held  still  over  any 
one  spot.  Where  the  growth  is  very  extensive,  radium  may  be  used  on 
the  worst  part  and  then  the  entire  surface  exposed  to  the  x-rays. 

The  disadvantages  of  radium  are  the  small  surface  from  which  the 
rays  proceed  and  its  enormous  cost. 

^  Williams,  Communications  of  the  Mass.  Med.  Soc,  1908,  xxi,  263. 


CHAPTER  XXXIX 

PREPARATION  OF  THE  PATIENT 

It  may  seem  somewhat  out  of  order  in  a  book  on  postoperative 
treatment  to  go  into  details  in  regard  to  the  matter  of  the  preparation 
of  the  patient  for  operation.  The  importance  of  preparation  and  the 
immense  influence  which  proper  or  improper  preparation  exerts,  how- 
ever, on  the  course  which  the  patient  will  follow  after  the  operation 
seem  to  me  sufficient  excuse  for  presenting  my  views  on  the  subject. 

The  literature  which  deals  with  this  subject  gives  an  immense  variety 
of  detailed  advice  and  instruction.  Each  individual  surgeon  is  likely 
to  be  persuaded  that  this  or  that  particular  procedure  has  been  the 
essential  in  his  successful  practice.  The  rules  laid  down  differ  so  widely 
that  one  must  conclude  that  the  only  good  rules  are  general  ones,  de- 
duced from  the  experience  of  many  men,  applied  and  varied  by  common 
sense  to  suit  each  case.  In  discussing  this  matter  of  preparation,  then, 
it  is  not  here  meant  to  be  arbitrary,  except  in  matters  of  principle,  but 
the  general  directions  here  given  may  be  followed  by  one  who  has  yet 
to  develop  his  own  peculiar  experience,  with  the  assurance  that  every 
detail  will  bear  the  pragmatic  test,  namely,  that  "it  works." 

It  is  a  trite  observation  that  every  surgeon  of  a  general  hospital, 
particularly  where  there  is  a  large  accident  clinic  and  other  emergency 
work,  cannot  fail  to  notice  that,  taken  by  large,  the  emergency  cases, 
operated  as  they  are  without  preparation  beyond  that  immediately 
preceding  operation,  seem  to  do  about  as  well  after  operation,  in  the 
way  of  comfort  and  complications,  as  the  patients  who  have  been  through 
a  long  course  of  preparation.  I  have  noted  this  so  many  times  that  I 
am  led  to  believe  that  that  part  of  preparation  which  includes  preopera- 
tive starvation  and  routine  catharsis  is  often  overdone,  that  starvation 
weakens  and  increases  the  liability  to  shock  and  acetonemia,  that  many 
patients  unused  to  cathartic  medicines  suffer  irritation  of  the  intes- 
tine and  notable  general  depression  from  their  use.  Such  preparation, 
moreover,  renders  more  likely  the  occurrence  of  intestinal  paresis,  with 
distention  and  nausea,  than  no  preparation  at  all.  Nor  does  there  seem 
to  be  any  reason,  in  theory  or  practice,  why  a  patient  more  or  less  starved 
348  ,  • 


CATHARSIS  349 

and  purged  should  better  endure  the  strain  of  operative  treatment  than 
one  who  is  well  nourished.  On  this  point  Ochsner  ^  says:  "As  a  rule, 
long-continued  preparatory  treatment  leaves  the  patient  in  a  much  less 
favorable  condition  for  a  surgical  procedure  than  a  very  short  and  simple 
preparation,  which  serves  to  put  the  kidneys,  the  skin,  and  the  alimentary 
canal  in  condition  favorable  to  elimination  of  the  waste  products.  .  .  . 
His  strength  is  not  impaired  by  confinement,  and  his  nervous  system  has 
not  suffered  by  looking  forward  to  the  operation  for  a  long  time.  Some 
years  ago  I  had  an  opportunity  to  observe  the  effect  of  waiting  for  a 
number  of  days,  and  sometimes  for  several  weeks,  to  allow  the  patient 
to  get  into  a  more  favorable  condition  for  operation,  and  I  am  positive 
that,  as  a  rule,  the  practice  is  bad." 

CATHARSIS 

For  the  iElective  Operation. — The  patient  is  told  to  take  a 
slightly  increased  dose  of  his  usual  cathartic  morning  or  night,  for  three 
days,  if  he  has  the  cathartic  habit.  If  customarily  he  has  not  required 
cathartics,  he  should  take  from  3  to  lo  gr.  of  extract  of  cascara  sagrada  at 
bedtime  on  three  successive  days  before  operation.  If  the  patient  is  of 
the  type  that  yields  more  kindly  to  morning  salts,  he  should  be  directed 
to  take  one  or  two  Seidlitz  powders,  or  i  to  3  dr.  of  effervescent  sodium 
phosphate,  or  a  dose  of  some  natural  or  artificial  aperient  water  on 
three  successive  mornings  instead.  The  night  before  operation  a 
simple  enema  of  soap-suds  (strong  soap)  should  be  given.  None  should 
be  administered  on  the  morning  of  operation  unless  the  case  calls  for 
surgery  of  the  rectum. 

For  the  iEmerg-ency  Operation. — Frequently,  to  aid  in  arriv- 
ing at  a  diagnosis  in  emergency  abdominal  conditions,  an  enema  has  to 
be  given.  In  case  this  has  not  been  done,  and  provided  there  is  no 
surgical  contra-indication,  an  enema  should  be  administered,  if  time 
permits  (and  usually  there  is  ample  time  while  preparation  of  room, 
instruments,  and  other  things  is  going  on) .  This  is  desirable,  if  for  no 
other  reason  than  because  by  it  we  can  start  our  operative  convalescence 
with  a  clear  lower  bowel,  hardened  masses  of  feces  being  much  easier 
to  remove  before  operation  than  after;  and,  furthermore,  if  the  patient 
must  be  stirred  up,  it  is  more  desirable  to  do  it  before  operation  than 
after.  The  enema  to  be  chosen  in  abdominal  cases  should  be  either 
the  compound  turpentine,  the  milk  and  molasses,  or  the  warm  glycerin. 
(See  p.  148.) 

*  Clin.  Surg.,  1902,  13. 


35°  PREPARATION    OF   THE   PATIENT 


DIET 


For  the  Elective  Operation.— It  is  obviously  undesirable  in 
all  abdominal  cases  to  have  much  stomach  or  intestinal  contents  present. 
In  preparation,  therefore,  the  patient  should,  for  three  or  four  days 
before  operation,  have  sufficient  food  to  keep  up  a  feeling  of  normal 
strength  and  no  more;  the  diet  should  be  limited  in  quantity  and  variety 
and  should  consist  of  simple,  easily  digestible  material.  The  diet  list 
should  not  contain  milk,  woody  vegetables,  or  any  other  food  which 
leaves  a  voluminous  residue.  Throughout  the  day  before  operation 
strong  broths — beef,  chicken,  or  mutton — ^with,  possibly,  a  litde  wine 
and  water,  should  be  given.  On  the  morning  of  operation,  at  any  time 
preceding  two  hours  before  the  starting  of  anesthesia,  black  coffee, 
plain  tea  or  sherry,  or  whisky  and  water  in  small  quantity,  may  be  given 
as  a  stimulant  to  body  and  spirit.  Exception  will  have  to  be  made  to 
this  rule,  of  course,  in  case  of  operation  on  stomach  or  duodenum. 

The  diet  in  emergency  operations  cannot,  of  course,  be  controlled. 

Experience  seems  to  show  that  a  considerable  increase  in  water- 
drinking  for  some  time  before  operation  is  desirable.  The  urine  is 
increased  thereby,  and,  to  a  certain  degree,  the  excretion  of  body  waste 
must  be  increased  also.  Baths  contribute  to  this  same  end.  A  thor- 
oughly clean  skin  must  be  an  asset  in  elimination  after  operation.  The 
day  before  operation,  then,  the  patient  is  to  be  given  a  warm  tub-bath 
or  a  thorough  sponge-bath  if  unable  to  leave  the  bed.  In  women,  where 
no  contraindication — such  as  virginity — exists,  a  vaginal  douche  of  2 
to  4  quarts  of  hot  water,  containing  a  dram  of  sodium  bicarbonate  to 
the  pint,  should  be  given. 

An  attempt  should  be  made,  if  time  and  circumstances  permit,  to 
have  the  teeth  and  month  clean,  even  if  the  services  of  a  dentist  are 
necessary.  There  can  be  no  question  but  that  a  clean  mouth  lessens  the 
probability  of  postoperative  parotitis.  I  believe  also  that,  as  post- 
operative throat  and  lung  complications  are  better  understood,  stricter 
attention  will  be  paid  to  mouth  cleanliness.  In  the  study  of  a  recent 
epidemic  of  noma  ^  the  following  conclusions  were  reached : 

"Any  uncared  for  mouth,  particularly  in  a  sick  child,  may  contain  bacillus 
fusiformis  and  spirochasta  gracilis.  In  such  a  mouth  these  organisms  may  be 
found  without  ulceradon  or  in  the  lesions  which  have  been  described  as  sto- 
matitis gangrenosa,  Vincent's  angina,  and  noma.     Any  of  these   conditions, 

^  Crandon,  Place,  and  Brown,  Boston  Med.  and  Surg.  Jour.,  1909,  clx,  473. 


DIET  351 

including  the  extensive  gangrene  and  sloughing  of  so-called  noma,  may  be 
different  stages  of  the  same  disease,  which  may  be,  therefore,  considered  as 
not  necessarily  a  specific  disease,  but  the  successful  ingress  of  mouth  bacteria 
into  tissues  rendered  non-resistant  by  uncleanliness  and  preceding  disease. ' ' 


Fig.  105. — Noma. 

Bacillus  fusiformis  and  spirochasta  gracilis,  normal    inhabitants  of   the  mouth.      The  disease   appears  in 

neglected  mouths  after  infective  diseases. 

Examination  of  the  urine,  chemical  at  least,  should  be  made 
in  all  cases,  not  that  the  presence  of  certain  urinary  abnormalities  would 
preclude  a  necessary  operation,  but  that  a  knowledge  of  the  condition 
of  the  avenues  of  elimination  should  be  had  in  anticipation  of  any  post- 
operative complications.  The  twenty-four-hour  amount  of  urine  should 
be  known  also,  if  possible. 

Preparatory  stimulation,  in  the  form  of  drugs,  tonics,  and 
massage,  must  vary  with  each  case;  they  may  be  the  deciding  factors  in 
the  outcome. 

The  value  of  a  complete  history  and  thorough  physical  examination 
cannot  be  overemphasized.  Such  a  routine  may  seem  irksome  and 
footless,  but  by  it  facts  of  the  greatest  clinical  importance  are  brought 
out,  ofteri  enough  to  make  the  value  of  complete  acquaintance  with  the 
patient  unquestionable.  Another  advantage  derived  from  complete 
examination,  as  Ochsner  ^  says,  is  that — "  If  the  surgeon  knows  that  all 
his  cases  are  to  be  examined  thoroughly  by  an  equally  competent  col- 
league or  assistant,  he  is  not  so  prone  to  become  careless  in  his  personal 
examination  as  his  work  accumulates."  Complete  examination  again 
and  again  brings  forth  a  possibility  we  are  apt  to  forget,  namely,  that  a 
patient  may  have  simultaneously  two  diseases. 

^  Clin.  Surg.,  1902,  13. 


352  PREPARATION    OF   THE   PATIENT 

FIELD  OF  OPERATION 

Except  for  the  warm  bath  the  night  before,  it  is  undoubtedly  better 
not  to  prepare  the  field  until  immediately  before  operation.  This  is 
true  for  the  following  reasons:  (i)  Shaving  or  scraping  may  cause 
minute  wounds  in  which  the  native  bacteria  of  the  skin  will  develop 
over  night.  (2)  The  heat  and  moisture  which  are  present  under  a 
preparatory  dressing  may  be  enough  to  cause  the  pouring  forth  and 
propagation  of  skin  bacteria  from  pores  and  hair-follicles.  On  the 
morning  of  operation  all  hair  in  the  vicinity  of  the  proposed  wound  should 
be  removed  by  careful  shaving  or  by  the  application  of  a  depilatory 
paste. 

Depilation  vs.  Shaving'. — Arbitrary  decision  as  to  the  relative 
values  of  shaving  and  depilation  of  the  field  of  operation  cannot  be  made. 
Some  surgeons,  notably  Robert  T.  Morris,  are  strongly  in  favor  of 
removal  of  hair  by  caustic  applications.  Shaving  long  before  the 
operation — the  day  before,  for  example,  as  is  done  in  many  hospitals — 
is  undoubtedly  bad  practice.  As  I  have  just  stated,  minute  wounds  are 
sure  to  be  made  by  the  nurse  or  orderly  who  does  the  shaving,  because 
of  the  contour  of  the  parts  to  be  shaved,  the  delicacy  of  the  skin, 
and  the  shrinking  movements  of  the  patient.  These  minute  wounds  on 
many  patients  will  show  signs  in  twelve  hours  of  mild  inflammation, 
small  hyperemic  areas  in  which  staphylococcus  albus  is  to  be  found. 
If,  in  addition,  the  old  method  of  moist  appHcations  over  night  in  pre- 
paration has  been  used,  the  spread  of  this  infectious  process  will  be  en- 
couraged. If  shaving,  therefore,  is  to  be  done,  it  should  be  done  only 
just  before  operation.  Most  of  the  depilatory  pastes  are  germicidal  as 
well,  and,  therefore,  are  to  be  commended.^ 

An  efficient  depilatory,  simple  to  prepare,  is  that  of  Boudet: 


Calcii  caustici  pulveri  (fresh  unslaked  lime) lo.o 

Sodii  sulphid  ^  (crystals) 3.0 

Amyli  (pulverized  starch) lo.o 

These  ingredients  are  separately  pulverized,  mixed,  and  kept  in  a 
bottle  dry  When  needed  for  use,  enough  water  is  added  to  form  a  thin 
paste.  This  is  spread  on  the  part  to  be  denuded  about  |  in.  thick  by 
means  of  a  wood  or  glass  spatula.     At  the  end  of  five  minutes  the  paste 

*  A  complete  list  of  formulas  may  be  found  in  Paschkis,  Cosmetik  fur  Aerzte,  Wien, 
1905,  pp.  256,  257. 

^  Barium  sulphid  mav  be  used  equally  well. 


DEPILATION 


353 


is  washed  off  with  sterile  water,  after  which  the  usual  preparation  pro- 
ceeds.^ 

Then  follows  the  important  part  of  the  preparation;  namely,  the 
scrubbing  with  soap  and  water.  Short  of  positively  injuring  the  skin, 
the  scrubbing  can  hardly  be  overdone.  Except  in  regions  such  as 
scalp,  axilla,  pubes,  hands,  or  feet,  the  scrubbing-brush  should  not  be 
used;  it  is  too  harsh.  The  person  who  does  the  preparation  should 
have  his  own  hands  thoroughly  cleaned  by  a  soap-and-water  scrub,  and 
may,  indeed,  well  wear  sterile  gloves.  For  preparation  of  the  field 
strong  soap  containing  pulverized  pumice  may  be  used,  or  any  strong 
soap  wrapped  in  one  layer  of  gauze  to  give  it  a  rough  surface,  vigorously 
scrubbing  it  up  and  down  and  round,  following  some  systematic  plan 
of  motions.  At  the  same  time,  at  intervals,  as  directed  by  the  scrubber, 
a  second  assistant  pours,  from  not  too  great  a  height,  hot  tap  or  sterilized 
water  from  a  pitcher.  By  this  means  the  dirty,  soapy  water  is  continu- 
ously being  washed  off  and  the  same  water  is  hardly  used  t\N'ice.  Dip- 
ping the  scrubbing  hand  back  and  forth  into  a  basin  is  a  slack  method. 
Instead  of  wrapping  the  soap  in  gauze,  a  handful  of  cut  gauze  and  tincture 
of  green  soap  may  be  used.  In  any  case,  enough  actual  lather  should 
be  raised  to  indicate  that  all  the  grease  in  the  soap  and  on  the  skin  has 

^  Robert  T.  Morris,  Amer.  Jour.  Surg.  Gyn.,  June,  1903,  xvi,  179: 
"When  the  depilatory  has  just  been  wiped  away  from  the  skin  after  about  five  minutes' 
application,  the  melted  hair  and  superficial  loose  epithelium  comes  away,  together  with 
any  dirt  that  lies  within  the  area  acted  upon.  The  skin  is  then  as  sterile,  apparently,  as 
it  would  have  been  after  the  labor  and  prolonged  methods  of  preparation,  and  we  have 
entirely  avoided  the  disturbance  caused  by  shaving.  The  time-saving  element  in  itself 
is  of  consequence.  I  have  taken  the  hair  from  an  entire  leg  in  less  time  than  it  would  have 
taken  to  shave  a  tenth  part  of  it,  to  say  nothing  of  the  fact  that  the  leg  was  all  ready  for 
operation  without  further  antiseptic  preparation.  We  can  plaster  the  depilatories  evenly 
over  the  skin  without  regard  for  their  entrance  into  the  open  wound,  as  the  germicidal 
influence  of  the  sulphites  will  counterbalance  any  irritating  effect. 

"  The  manufacturers  of  depilatories  advertise  them  as  harmless.  This  is  not  true. 
They  are  about  as  capable  of  harmful  influence  as  are  carboHc  acid  and  bichlorid  of  mer- 
cury, and  need  to  be  used  with  as  much  care  as  we  employ  with  these  two  standard  anti- 
septics. In  removing  the  hair  from  the  vulva,  for  instance,  the  mucous  membranes  of 
the  labia  are  sometimes  irritated  by  the  depilatories  unless  we  first  brush  the  mucous 
membranes  with  a  little  sterile  oil  for  protection  from  plastering  the  whole  \'ulva  with  the 
paste.  On  the  skin  of  some  patients  the  depilatories  have  the  effect  of  taking  off  small, 
superficial  patches  of  epithelium,  so  that  one  will  often  need  to  brush  these  spots  with 
sterilized  oil.  Nurses  are  apt  to  dislike  the  staining  of  the  nails  from  the  action  of  sul- 
phids  when  preparing  a  patient  for  operation,  but  one  can,  with  a  little  care,  avoid  staining 
the  finger-nails.  - 

"  On  the  whole,  however,  the  use  of  germicidal  depilatories  is  such  an  advance  over  the 
older  methods  of  preparation  of  the  skin  of  the  patient  that  I  believe  it  to  be  the  coming 
method,  and  my  nurses  and  assistants  would  not  like  to  go  back  to  the  troublesome  methods 
that- are  as  yet  in  common  employment." 
23 


354  PREPARATION    OF   THE   PATIENT 

been  saponified.  The  soap  is  now  thoroughly  washed  off  with  con- 
tinued hbation  of  sterile  water.  A  small  amount  of  ether  may  now  be 
used  if  the  surgeon  thinks  best  to  remove  any  fat  or  grease  which  has 
been  left  on  the  skin.  \A'hether  this  step  is  taken  or  not,  70  per  cent, 
alcohol  is  next  applied  and  thoroughly  scrubbed  all  over  the  field,  using 
a  sterile  sponge  of  gauze.  Assurance  is  made  doubly  sure  if  at  this 
stage  Harrington's  solution  is  used.^  An  alcohol  saturated  pad  is  now 
left  over  the  site  of  incision  while  the  sterile  sheets,  towels,  and  other 
coverings  are  being  placed  over  the  patient.  This  is  removed  by  the 
surgeon  at  the  moment  of  incision. 

In  the  scrubbing  particular  attention  should  be  paid  to  the  region 
of  the  umbilicus,  which  is  to  be  very  thoroughly  washed  with  a  cork- 
screw motion,  to  the  folds  under  pendulous  breasts,  and  to  the  groins, 
especially  if  the  abdomen  is  pendulous.  If  the  skin  in  any  of  these 
areas  is  eczematous,  the  operation  should  be  postponed,  if  possible, 
until  the  condition  has  been  cleared  up.  If  the  operation  must  go  on, 
and  these  areas  come  at  all  within  the  field,  they  should,  for  the  time 
being,  be  sealed  with  absorbent  sterile  gauze  and  the  whole  covered  with 
collodion.  This  also  applies  to  blistered  areas  where  escharotics,  plas- 
ters, or  hot-water  bags  have  caused  breaks  in  the  skin.  If  operation 
is  imperative  through  such  area,  the  region  may  be  scraped  with  a  curet 
and  just  before  operation  painted  t^vice  over  with  tincture  of  iodin. 
Then,  in  addition,  a  whole  sheet  is  placed  over  the  area  and  incision  made 
through  sheet  and  skin.  Whatever  is  thereafter  inserted  into  the  wound 
does  not  rub  over  this  questionable  area  of  skin. 

.  ^  Dr.  Charles  Harrington,  of  Boston  (Trans.  Amer.  Surg.  Assoc,  1904,  xxii,  41,  et  seq.)^ 
made  a  careful  comparative  study  of  all  the  antiseptics  used  at  present,  and  as  a  result 
of  that  study  devised  a  mixture  which,  on  experimentation,  proved  to  combine  the  greatest 
germicidal  action  with  the  least  irritation: 

Corrosive  sublimate 0.8  gm. 

Commercial  alcohol  (94  per  cent.) 640.0  cc. 

Hydrochloric  acid 60.0  cc. 

Water 300.0  cc. 

This  mixture  contains  corrosive  sublimate,  i:  1250,  in  a  solution  made  up  of  6  per  cent, 
hydrochloric  acid  and  60  per  cent,  absolute  alcohol.  Sixty  per  cent,  alcohol  will  destroy 
staphylococcus  aureus  in  four  minutes;  10  per  cent,  hydrochloric  acid  is  equally  effective, 
and  1 :  1000  corrosive  sublimate  will  kill  it  in  three  minutes.  Why  a  combination  contain- 
ing all  these  substances,  but  with  lesser  proportions  of  the  acid  and  salt,  is  so  much  quicker 
in  its  action  than  any  one  of  them  alone,  is  an  interesting  question  of  physical  chemistry. 
But  such  is  the  fact.  After  giving  the  hands  an  ordinary  wash  and  soaking  in  the  solution 
two  minutes,  all  culture  tests,  even  under  the  nails,  are  sterile. 


PREPARATION    OF   SPECIAL   AREAS  355 

PREPARATION  OF  SPECIAL  AREAS 

Scalp. — For  all  scalp  wounds,  removal  of  wens,  and  such  minor 
matters,  if  surgeon  and  patient  are  willing  to  give  up  enough  time  for 
thorough  scrubbing,  little  if  any  shaving  need  be  done.  The  scrubbing 
must  be  thorough,  however,  with  strong  soap  and  a  brush,  the  hair  care- 
fully separated  in  the  region  to  be  treated,  and  the  work  then  carried  on 
through  a  hole  cut  in  a  towel  or  sheet.  If  no  shaving  has  been  done, 
a  cocoon  dressing  cannot  be  applied,  but  a  corrosive  or  carbolic  pad 
will  have  to  be  put  on  after  sewing. 

For  all  operations  on  the  skull  itself  complete  shaving  of  the  head 
must  be  done,  because,  if  for  no  other  reason,  one  can  never  tell  how 
extensive  an  operation  may  be  necessary.  It  is  always  easy,  however, 
to  induce  the  patient  to  allow  shaving  by  telling  him  that  the  cosmetic 
effect  of  complete  removal  of  the  hair  is  better  than  partial  shaving. 

The  Region  of  Beard  and  Eyebrows. — The  beard  or  mus- 
tache, when  the  operation  involves  these  regions,  might  better  be  en- 
tirely removed,  but  even  to  this  rule  there  may  be  exceptions,  and  a 
perfectly  clean  operation  may  be  done,  if  the  reasons  are  sufficient, 
through  a  bearded  area. 

It  will  rarely  be  necessary  to  shave  the  eyebrows,  inasmuch  as  the 
hair  is  so  short  and  so  sparse  that  it  should  be  perfectly  cleanable,  and 
the  absence  of  an  eyebrow,  even  for  a  short  time,  is  a  rather  important 
cosmetic  matter  to  a  sensitive  person, 

For  a  mastoid  operation  a  zone  of  scalp  behind  the  ear,  | 
to  I  in.  in  width,  should  be  denuded  of  hair. 

All  other  hairy  areas  of  the  body  should  be  entirely  denuded 
of  hair  in  preparation  for  any  operation. 

Mouth. — Though  complete  asepsis  of  the  mouth  is  probably  not 
attainable,  much  may  be  done.  Most  of  the  cleaning,  however,  is  me- 
chanical, since  antiseptics  of  sufficient  strength  to  be  efficient  cannot 
be  used  with  safety.  If  it  is  possible,  the  teeth  should  be  thoroughly 
cleaned  by  a  dentist  and  bad  teeth  either  filled  or  removed.  An  excel- 
lent antiseptic  to  be  applied  to  gums  at  the  line  of  contact  with  the  teeth, 
the  commonest  site  of  mouth  infection,  is  the  following: 

^-   Zinciiodidi   X  --  ggg 

lodi  i  

Glycerini q.  s.  ad  §ij. 

This  is  applied  with  a  brush  or  cotton-stick  intimately  around  the  base 
of  each  tooth.  The  mouth  should  be  washed  by  the  patient  every 
hour  or  two  for  two  days  preceding  the  operation.     At  the  time  of  opera- 


356  PREPARATION    OF    THE    PATIENT 

tion  the  whole  mouth  may  be  scrubbed  out  by  the  surgeon  with  boric 
acid,  4  per  cent.,  or  full  strength  liquor  antisepticus,  or  some  such  cleans- 
ing fluid.  Gargling  is  good  as  a  mouth-wash,  but  absolutely  without 
value  for  the  pharynx,  as  may  be  proved  by  any  one  who  will  gargle  with 
a  staining  fluid  and  then  examine  the  mouth.  The  stain  will  not  go,  as 
a  rule,  beyond  the  anterior  pillars. 

The  nose  similarly  should  be  cleansed  by  the  surgeon  at  the  mo- 
ment of  operation. 

Vagina,  Cervix,  and  Genital  Region. — Here,  too,  the  most 
valuable  cleansing  is  mechanical.  On  the  table  a  douche  should  be 
given,  thoroughly  distending  all  the  folds,  then  the  whole  cavity  scrubbed 
out  with  soap  and  water  and  gauze,  the  manipulations  not  being  too 
rough.     Another  douche  follows. 

Few  women  know  how  to  take  an  efficient  vaginal  douche.  Most 
nurses  know  little  about  it,  and  many  doctors  let  their  directions  end, 
"Take  a  hot  douche  morning  and  night,"  without  any  details. 


Fig.  106. — Vaginal  Dodche. 
Hammock  of  canvas  suspended  on  metal  side-bars  in  bath-tub,  designed  to  give  proper  elevation  of  pelvis. 
The  shoulders  are  supported  on  the  lower  cross-piece,  the  buttocks  on  the  higher,  and  the  feet  may  conve- 
niently rest  on  the  rim  of  the  tub  at  its  lower  end. 

Most  women  take  a  douche  sitting,  in  which  position  the  walls  of  the 
vagina  are  entirely  pressed  together  by  the  weight  of  the  viscera.  The 
cleansing  fluid  under  these  conditions  cannot  at  all  distend  the  folds 
and  the  douche  must  fail  more  or  less  in  its  purpose.  Some  women 
take  douches  lying  on  the  bed-pan.  This  is  a  better  position,  but  even 
taken  in  this  way,  the  woman  is  likely  to  be  partly  reclining  on  three  or 
four  pillows  till  the  body  is  really  inclined  downward  toward  the  but- 
tocks, with  the  same  compression  of  the  vagina.  The  fluid  wets  her 
clothing,  the  bed,  and  the  floor,  and  does  not  r^ach  the  parts  for  which 
it  is  intended. 

A  vaginal  douche  should  always  be  taken  lying  on  the  back,  with 
the  buttocks  raised  at  least  6  in.  above  the  level  of  the  shoulders.  Such 
a  position  may  be  obtained  by  a  specially  devised  hammock  which 
may  be  hung  in  a  bath-tub  ^  (see  Fig.  106) ,  or,  more  simply,  the  douche 
may  be  taken  lying  on  the  floor  with  a  douche  pan,  but  under  the  douche 

^  Boston  Med.  and  Surg.  Jour.,  1908,  clix,  795. 


PREPARATION    OF    SPECIAL    AREAS 


357 


pan  a  pad  or  pillow  of  rubber  or  stork-sheeting,  filled  with  excelsior, 
the  whole  sufficient  in  height  to  lift  the  buttocks  well  above  the  level 
of  the  shoulders.  In  this  position  the  vagina  bellows  out,  the  fluid 
injected  distends  it  thoroughly,  comes  in  contact  with  every  part,  and 
insures  all  the  benefits  of  moisture,  heat,  and  medication  to  vagina, 
cervix,  and  pelvic  floor. 


Fig.  107. — Burn  Resulting  from  a  Self-administered  Douche  oe  Undiluted  Creolin. 
(Case  of  Dr.  N.  R.  Mason;  photograph  loaned  by  Dr.  R.  D.  Hildreth.) 

Rectum. — On  the  table,  under  anesthesia,  is  the  time  for  rectal 
cleansing,  and  then  only  after  eight  or  ten  minutes  have  been  taken  to 
slowly  and  thoroughly  dilate  the  sphincter  ani  to  a  thoroughly  paretic 
condition.  Under  these  conditions  irrigation  with  salt  solution,  with 
the  tube  inserted  not  over  6  in.,  thoroughly  cleans  rectum  and  sigmoid. 

Bladder  and  Urethra. — So  many  of  the  operations  in  this 
region  are  for  obstructive  conditions  of  the  urethra,  it  is  frequently  not 
possible  to  vv^ash  out  either  bladder  or  urethra.  Where  it  is  possible 
it  should  be  done  with  warm  boric-acid  solution,  2  per  cent.,  in  and  out 
several  times. 

Hands  and  Feet.— These  regions  with  thickened  skin,  so  much 
more  exposed  than  other  parts  to  sources  of  infection,  should  be  pre- 
pared for  operation  by  long-Tepeated  soaking  in  hot  soapy  water,  or, 
better  still,  soapy  water  with  the  addition  of  a  little  chlorinated  soda 
(liquor  sodai  chlorinata?) .  Hands  or  feet,  soaked  for  half  an  hour 
every  four  hours  the  day  before  operation,  or,  in  any  case,  two  periods 
before,  can  have  all  the  overthickened,  macerated  epidermis  then 
scraped  off. 


PART  11 

CHAPTER  XL 
OPERATIONS  ON  THE  HEAD  AND  FACE 

SCALP  WOUNDS 

Aseptic  Wounds. — The  primary  gauze  dressing  of  a  large  wound 
may  be  removed  on  the  third  day  and,  if  there  appears  to  be  no  sepsis, 
a  cocoon  substituted.  On  the  eighth  or  tenth  day  the  cocoon  and  the 
stitches  are  removed. 

Septic  Wounds.— If,  after  the  first  twenty-four  hours,  there  is 
considerable  throbbing,  pain,  or  increasing  tenderness,  it  is  probable 
that  some  grade  of  infection  is  present.  The  dressing  should  be  re- 
moved, perhaps  a  stitch  or  t^vo  removed  to  let  out  retained  serum,  and 
wet  dressings  applied.  A  culture  may  be  taken.  Infection  of  scalp 
wounds  sometimes  is  fulminating  in  character.  The  appearance  of 
edema  about  the  eyes  or  behind  the  ears,  together  with  headache,  vertigo, 
and  perhaps  delirium,  should  be  looked  upon  as  an  indication  of  grave 
import.  In  such  cases  the  wound  should  be  laid  freely  open  and  other 
drainage  wounds  made.  (See  Septic  Wounds,  p.  225.)  The  general 
treatment  of  septicopyemia  (see  p.  252)— bed,  ice-cap,  wet  dressings, 
stimulation,  and,  in  appropriate  cases,  vaccine  therapy— should  be 
begun  at  once. 

Septic  Wounds  with  Necrotic  5o/ie.— Scalp  wounds  going  down  to 
the  bone,  when  septic,  are  characterized  by  a  profuse  purulent  discharge, 
due,  in  frequent  instances,  to  the  presence  of  necrotic  bone.  When  this 
process  of  necrosis  occurs,  it  will  continue  from  ten  to  sixteen  weeks 
and  end  by  the  separation  of  the  superficial  plates  of  dead  bone,  which 
is  followed  by  prompt  healing.  Probably  very  little,  if  any,  time  is 
saved  by  operative  attempts  to  remove  the  dead  bone  before  it  is  ready 
to  separate. 

TREPHINING  AND  BRAIN  OPERATIONS 

It  is  assumed  that  the  dura  has  been  sewed  over  the  brain  so  far  as 
possible.  Drainage  is  best  made  with  rubber  dam.  This  serves  to 
carry  away  the  steady  ooze  of  blood  and  serum  which  takes  place 

358 


TREPHINING   AND   BRAIN    OPERATIONS  359 

at  the  operative  site  during  the  first  twenty-four  hours.  Its  removal 
then  is  advisable  in  order  that  the  normal  intracranial  tension  may  be 
gradually  restored.  This  tension  in  septic  cases,  with  careful  hemostasis, 
is  never  sufficient  to  interfere  with  primary  healing,  and,  at  the  same 
time,  it  exerts  a  salutory  pressure  on  the  brain,  which  tends  constantly 
to  extrude  through  the  wound,  and  helps  also  to  prevent  direct  adhesion 
between  the  scalp  and  the  dura  or  brain  beneath  it  by  the  formation 
of  soft  connective  tissue. 

In  cases  of  osteoplastic  resection  by  the  DeVilbiss  cranial  bone- 
gouge,  or  by  any  other  method  which  has  for  its  purpose  the  preservation 
of  the  bone-flap,  prolonged  suppuration  is  the  only  sign  by  which  we 
can  conclude  that  the  bone-flap  is  not  alive.  Secondary  operation 
becomes  necessary. 

Trephined  cases  may  have  several  pillows  almost  immediately  after 
ether  recovery,  but  should  be  kept  in  bed  and  restrained  from  all  mus- 
cular effort  for  two  weeks.  Straining  at  stool  should  in  particular  not 
be  allowed. 

Complications  and  Sequelae. — (i)  The  anesthetic  may  not  he 
well  taken.  "If  there  is  no  contra-indication,  \  gr.  of  morphin  before 
.operation  is  desirable,  since  the  amount  of  anesthetic  will  be  then  cut 
down.  The  morphin  also  contracts  the  arterioles  of  the  brain  and 
diminishes  bleeding.  In  unconscious  cases,  of  course,  neither  the 
morphin  nor  anesthetic  is  needed.  If  the  shock  is  not  profound,  and 
there  is  no  other  good  reason  against  chloroform,  this  anesthetic  should 
be  used — first,  because,  contrary  to  ether,  it  produces  cerebral  depres- 
sion, and,  second,  because  there  is  less  vomiting.  Anesthol  is  taken  well 
in  cerebral  cases."  ^ 

(2)  Postoperative  hemorrhage  may  appear,  often,  apparently,  started 
up  by  vomiting.  If  it  is  from  cerebral  vessels,  little  can  be  done  beyond 
packing;  if  from  the  dura  or  sinuses,  a  secondary  operation  must  be 
done  at  once  to  control  the  bleeding;  if  from  the  diploe,  it  may  be  con- 
trolled'by  plugging  with  bone  wax  or  the  hot  drippings  of  a  candle. 

(3)  Shock  may  be  profound,  and  should  be  combated  on  general 
principles. 

(4)  Edema  of  the  lungs  is  likely  to  follow  long  anesthesia. 

(5)  Hernia  Cerebri. — This  may  occur  (a)  immediately,  during  the 
operation,  where  there  exists  much  intracranial  pressure  which  it  has 
not  been  possible  entirely  to  relieve.  It  may  appear  {h)  later,  as  the 
result  of  an  intracranial  collection  of  serum  or  pus.  If  such  a  collection 
is  then  drained  and  the  pressure  relieved,  the  brain  may  be  held  in  with 

*  Jacobson  and  Steward,  i,  314. 


360  OPERATIONS    ON    THE    HEAD    AND    FACE 

a  piece  of  sheet  silver  or  lead.  Actual  hernia  of  the  brain  should,  of 
course,  be  distinguished  from  false  hernia,  which  is  due  to  a  so-called 
red  softening  of  the  brain,  or  is  composed  of  granulation  tissue.  Real 
hernia  of  the  brain,  if  it  is  not  reducible  under  slight  and  sustained 
pressure,  should  be  treated  by  resection  of  the  entire  mass  at  the  end 
of  two  or  three  weeks.  False  hernia  cerebri  should  be  treated  like 
granulation  tissue,  cut  off  at  once,  and  further  growth  checked  by  pres- 
sure and  caustics,  if  necessary,  while  epidermatization  is  being  en- 
couraged. 

(6)  Infection  is  particularly  liable  to  occur  in  brain  cases,  partly 
because  of  the  traumatic  etiology  of  a  large  proportion  of  conditions 
necessitating  operation  upon  the  skull,  and  partly  because  of  the  diffi- 
cult)'- of  establishing  and  maintaining  complete  asepsis  during  a  cranial 
operation.  If  general  symptoms  manifest  themselves  immediately,  it  is 
either  a  diffuse  encephalitis  or  a  meningitis  and  proves  rapidly  fatal. 
Most  free  drainage  and  general  treatment  for  septicopyemia  are  the  only 
resources. 

REMOVAL    OF    THE    GASSERIAN    GANGLION    AND    OTHER    NERVE 

RESECTIONS 

The  wounds  after  these  operations  should  all  heal  by  first  intention. 
Prolonged  stay  in  bed  is  uncalled  for.  Pain  may  appear  in  correspond- 
ing parts  on  the  other  side  of  the  face  and  demand  sedatives  for  the  first 
few  days. 

Paralysis  of  the  eyelids  calls  for  protection  of  the  conjunctiva  at  first 
until  the  eye  learns  to  roll  itself  under  cover.  The  conjunctiva  should 
be  washed  out  with  2  per  cent,  boric-acid  solution  or  sterile  water  every 
hour  or  t^vo.  Drooling  from  the  paralyzed  corner  of  the  mouth  irritates 
the  skin,  but  control  of  the  mouth  to  a  degree  to  prevent  escape  of  saliva 
is  soon  resumed. 

EXCISION  OF  THE  UPPER   OR   LOWER   JAW 

Packing  of  iodoform  or  other  kind  of  gauze  which  was  put  in  at  the 
end  of  the  operation  should  be  removed  at  the  end  of  t\venty-four  hours. 
The  patient  is  best  kept,  after  ether  recovery,  in  approximately  a  sitting 
position,  to  facilitate  drainage  downward  and  forward.  The  cavity 
should  be  washed  out  with  an  alkaline  antiseptic,  or,  if  not  too  painful, 
it  may  be  better  cleansed  by  means  of  gargling  on  the  part  of  the  patient 
himself.  Food  should  be  given  through  a  tube  for  the  first  few 
days. 


TUMORS  OF  THE  PAROTID  36 1 

Complications  and  Sequelae. — (i)  Prolonged  shock  may  ap- 
pear, though  it  is  rare.  This  is  to  be  treated  in  accordance  with  the 
principles  already  laid  down.     (See  p.  82.) 

(2)  Hemorrhage. — If  it  resists  the  use  of  adrenalin  or  ice,  packing 
should  be  tried;  if  necessary,  the  wound  must  be  opened  and  the  bleeding 
point  found  and  plugged  or  tied. 

(3)  Sepsis. — Some  degree  of  infection  must  always  occur;  it  may 
amount  to  an  erysipelas.  This  complication  calls  for  the  usual  treat- 
ment. (See  p.  254).  If  the  tumor  removed  was  sarcoma,  erysipelatous 
infection  is  welcomed.     (See  Chapter  LIII.) 

(4)  Bronchopneumonia  very  often  appears,  especially  in  aged  patients, 
from  inhalation  of  blood,  pus,  or  food,  and  is  not  infrequently  the  second- 
ary cause  of  death.  Preventive  treatment  is  the  most  important — namely, 
careful  antiseptic  preparation  of  the  mouth  before  operation  and  great 
care  in  preventing  choking  and  cough  during  feeding.  The  mouth 
and  wound  should  be  thoroughly  cleansed  by  irrigation  and  with  gauze 
and  forceps  at  least  every  four  hours  and  after  each  meal. 

(5)  Recurrence  of  the  Tumor. — Attempts  should  be  made  to  prevent 
recurrence  of  the  tumor,  depending  upon  the  type  of  new-growth  present. 
At  the  present  writing,  our  only  resource  in  sarcoma  seems  to  be  the 
Coley  serum  (see  Chap.  LIII) ;  in  carcinoma,  :v-ray  therapy  (see  p.  341). 

If  the  excision,  after  thorough  healing,  seems  to  lead  to  the  hope  that 
success  has  been  attained  in  its  object,  the  problem  of  apparatus  to  fill 
out  the  contour  of  the  face  and  to  provide  for  chewing  is  one  that  the 
surgeon  must  refer  to  dentists  skilled  in  such  work. 

TUMORS  OF  THE  PAROTID 

If  none  of  the  greater  radicles  of  the  duct  have  been  cut,  the  wound 
or  wounds  should  heal  by  first  intention.  The  stitch  or  stitches  may 
come  out  with  perfect  safety  on  the  fifth  day.  The  patient  may  be  up 
as  soon  as  the  effects  of  the  ether  are  over. 

Complications  and  Sequelae. — (i)  Facial  Paralysis. — The 
facial  nerve  may  have  been  cut  by  mischance  or  it  may  have  been  cut 
necessarily  to  allow  of  removal  of  the  growth.  After-treatment  consists 
only  in  protecting  and  cleaning  the  conjunctiva  of  the  paralyzed  eye 
until  it  is  accustomed  to  the  new  conditions.  Later,  nerve  anastomosis 
may  be  indicated. 

(2)  Parvtid  Fistula.— Sections  of  the  gland  may  be  temporarily 
isolated  by  operation,  and  within  a  week  or  ten  days— perhaps  some- 
what longer — reestablish  drainage  by  their  normal  ducts.  If,  after  a 
sufficient  interval,  it  becomes  evident  that  a  definite  fistula  has  formed, 


362  OPERATIONS    ON    THE    HEAD    AND    FACE 

a  seton  of  coarse  twisted  silk  is  put  into  the  fistulous  opening,  through 
the  cheek  into  the  mouth  cavity,  and  tied  in  a  loop  out  through  the 
mouth.  From  time  to  time  this  is  pulled  through  until  the  opening  is 
well  established  into  the  mouth.  It  is  then  removed;  the  edges  of  the 
skin  wound  are  freshened  and  sewed  up. 

ENUCLEATION  OF  THE  EYE 

Immediately  following  enucleation  there  is  considerable  hemorrhage 
for  a  minute  or  two.  As  a  rule,  this  gradually  ceases;  it  may,  very 
rarely,  be  necessary  to  use  pressure  at  the  apex  of  the  orbit.  There 
is  ordinarily  but  little  bleeding  after  four  or  five  minutes.  The  orbital 
cavity  must  be  irrigated  at  once  with  sterile  water,  normal  salt  solution, 
or  with  a  3  per  cent,  solution  of  boric  acid,  until  all  clots  of  blood  are 
removed.  Clean  up  the  eyelids  and  surroundings,  and  then  introduce 
about  I  dr.  of  some  simple  antiseptic  ointment  inside  the  eyelids.  This 
prevents  the  secretions  from  gluing  together  the  lid  margins.  Over  the 
closed  eyelids  apply  numerous  layers  of  sterile  gauze  cut  in  small 
squares,  making  in  all  a  pad  about  ih  in.  thick,  extending  from  the 
brow  to  the  cheek,  and  from  the  nose  to  the  temple.  This  should  be 
held  in  place  by  a  2 -in.  monocular  roller-bandage,  applied  snugly  but 
not  tight  enough  to  produce  discomfort. 

The  following  day  the  patient  may  sit  up  out  of  bed.  The  bandage 
is  removed,  and  the  margin  of  the  eyelids  cleansed  with  small  sterile 
gauze  sponges  or  cotton  balls  wet  in  a  3  per  cent,  solution  of  boric  acid 
and  then  redressed  in  the  manner  described  above.  More  or  less  re- 
action in  the  form  of  ecchymoses  and  swelling  of  the  lids  will  be  observed 
at  this  time,  although  in  a  few  cases  it  is  hardly  noticeable.  It  is  usually 
a  little  more  marked  when  a  glass  or  gold  sphere  has  been  implanted 
in  Tenon's  capsule,  but  all  signs  usually  disappear  in  about  t\vo  weeks. 

The  dressing  should  be  changed  once  daily,  preferably  in  the  morn- 
ing. The  bandage  may  be  omitted  in  three  or  four  days  after  simple 
enucleation,  and  in  six  or  seven  days  when  a  sphere  has  been  implanted. 
After  this  period,  cleanse  the  cavity  and  lids  with  a  solution  of  boric 
acid  three  times  a  day  and  apply  an  ointment  to  margin  of  lids  at  bed- 
time. 

Remove  the  silk  conjunctival  suture  in  six  or  seven  days;  after  this  the 
patient  may  be  discharged  from  the  hospital.  Occasional  cleansing 
with  a  solution  of  boric  acid  to  remove  any  secretion  which  may  form 
is  the  only  subsequent  treatment  necessary.  A  single  eyeshade  may  be 
worn  for  cosmetic  effect  until  a  glass  eye  can  be  fitted.  This  may  be 
done  as  soon  as  the  wound  has  healed  and  the  discharge  ceased  and 


OTHER    PLASTIC    OPERATIONS    ON    THE    FACE  363 

all  swelling  has  disappeared.     As  a  rule,  it  is  better  to  wait  three  or 
four  weeks  before  having  the  artificial  eye  fitted. 

Rarely  a  button  of  granulation  tissue  forms  at  the  center  where  the 
cut  edges  of  the  conjunctiva  meet.  This  should  be  snipped  off  with 
scissors. 

OTHER  PLASTIC  OPERATIONS  ON  THE  FACE 

It  is  somewhat  difi&cult  to  deal  with  this  matter  solely  from  the 
point  of  view  of  after-treatment,  since  common  sense  must  dictate 
the  specific  treatment  for  special  cases.  In  general,  however,  by  position 
or  by  the  application  of  plaster  straps,  all  tension  must  be  kept  off  the 
sutures  so  far  as  is  possible.  The  wound  itself  might  better  be  not  closed 
in  by  any  dressing,  but  rather  left  exposed  to  the  air,  and  frequently 
cleaned  with  alcohol  or  painted  with  the  compound  tincture  of  benzoin 
or  some  such  application.^  The  stitches  will  have  served  their  purpose 
in  most  instances  by  the  sixth  day,  and  should  be  removed  then  in 
order  to  avoid  forming  stitch  scars. 

Haemorrhage  must  be  thoroughly  stopped,  since  a  relatively  thin 
layer  of  blood-clot  may  prevent  a  plastic  flap  from  adhering.  Firm 
pressure,  therefore,  for  an  hour  or  two,  even  if  it  has  to  be  applied  con- 
tinuously by  a  nurse's  hand,  may  be  necessary.  Too  much  detailed 
care  can  hardly  be  given  in  these  important  cases.  From  the  beginning, 
when,  as  Treves ^  says,  "Each  flap  must  be  gently  handled,  carefully 
adjusted,  and  most  tenderly  and  precisely  sutured, "  up  to  the  sixteenth 
to  the  twenty-first  day,  during  which  time  there  must  be  no  tension, 
strict  cleanliness  must  be  maintained.  During  the  early  restlessness 
after  operation  and  during  sleep  it  is  safest  even  to  overdo  the  applica- 
tion of  harness,  straps,  or  other  apparatus  to  prevent  sudden  movements 
which  may  disturb  the  flaps. 

Skin-grafting. — Where  this  procedure  has  been  used,  in  addition  to 
plastic  flaps,  for  special  care  see  p.  572. 

^Antiseptic  Varnish: 

Iodoform  or  aristol  (thymol    iodid)  -i  -^  ^        j. 

Glycerin  i 

Tinct.  benzoin.,  comp 4  parts. 

^  Oper.  Surg.,  1892,  ii,  3. 


CHAPTER  XLI 
OPERATIONS  ON  THE  MOUTH,  NOSE,  AND  PHARYNX 

HARE-LIP 

The  difficulties  of  feeding  a  child  after  this  operation  have  been 
somewhat  exaggerated.  After  the  operation  a  piece  of  gauze  or  some 
antiseptic  varnish  (see  p.  363),  or  both,  is  applied  over  the  wound,  and  all 
side-pull  on  the  wound  is  prevented  by  a  dumb-bell-shaped  piece  of  zinc 
oxid  plaster.  The  crinolin  covering  adherent  to  that  part  of  the  plaster 
which  crosses  the  hp  itself  is  left  so  that  the  plaster  does  not  stick  to  any 
part  of  the  lip,  but  only  to  the  cheek.  The  upper  lip  is  necessarily  so 
crumpled  together  by  this  plaster  apphcation  that  sucking  would  be 
impossible,  even  if  it  were  best  for  the  lip  for  other  reasons.  The  child 
must  be  fed,  then,  with  a  small  spoon,  put  well  into  the  mouth.  The 
mother's  milk  should  be  drawn  and  given  if  possible.  The  child  is 
first  given  water,  just  as  any  ether  patient  would  have  it,  but  if  it  is 
weak  on  account  of  poor  general  condition  or  from  shock,  the  milk 
should  be  offered  within  three  hours  of  the  operation.  Bottle-feeding — 
a  large  nipple  is  advantageous — may  be  resumed  in  three  days;  breast- 
feeding at  the  end  of  ten  days,  the  breasts  being  kept  active  during  the 
interval. 

Sutures  should  be  removed,  in  part,  as  early  as  five  days — all  by 
ten  days.  At  the  moment  of  their  removal  all  tension  on  the  lip  must 
be  prevented,  and  a  new  butterfly  plaster  applied  at  once,  as  before,  in 
order  that  the  newly  formed  scar  shall  not  be  subjected  to  strain  and 
widen.     This  butterfly  is  worn  up  to  three  weeks. 

Complications  and  Sequelae. — (i)  Asphyxia. — In  the  younger 
infants  this  calamity,  unless  carefully  guarded  against,  may  frequently 
occur.  It  cannot  be  better  described  than  in  the  words  of  Mr.  Jacob- 
son:^  "One  point  of  great  importance  is  not  alluded  to  in  surgical 
works,  and  that  is,  that  in  some  cases  of  hare-lip  death  from  dyspnea 
may  take  place  very  soon  after  operation,  Thus,  where  the  cleft  has 
been  a  large  one  and  the  upper  hp  when  restored  is  tight,  where  it  over- 
hangs the  lower,  if  the  nostrils  are  flattened  and  partly  closed  by  the 
operation,  owing  to  the  tension  of  the  parts,  so  little  breathing  space 

^  Loc.  cit.,  410. 
364 


CLEFT-PALATE  365 

may  be  left  that  temporary  interference  with  respiration  may  occur, 
with  grave  and  even  fatal  results  before  the  breathing  can  be  accom- 
modated to  the  altered  circumstances  and  before  the  parts  dilate  and 
stretch." 

(2)  Many  children  die  after  this  operation,  particularly  the  young 
ones.  For  that  reason  it  is  probably  best,  despite  the  clamors  of  the 
parents,  to  postpone  the  operation  for  this  deformity  until  the  child  is 
from  six  to  nine  months  old.  This  rule,  of  course,  does  not  hold  if  the 
child  cannot  well  nourish  itself  on  account  of  the  deformity.  Many  of 
the  infants  that  die  under  this  operation  are  of  the  marasmic  type  that 
rarely  live,  operated  on  or  not. 

(3)  Hemorrhage  may  be  serious,  especially  in  a  weak  infant.  Prop- 
erly placed  stitches  should  hold  the  coronary  arteries.  Apart  from 
the  primary  dangers  of  hemorrhage  any  considerable  collection  of  clot 
under  the  lip  or  between  the  edges  leads  to  non-union.  The  fauces  may 
even  fill  up  with  blood-clot,  and,  unless  the  child  is  watched  carefully, 
death  ensues  from  suffocation. 

(4)  Bronchopneumonia  is  liable  to  occur,  as  in  any  infant  after 
etherization,  and  particularly  after  mouth  operations. 

CLEFT-PALATE 

A  small  injection  of  morphin  may  be  given  immediately  after  the 
operation,  but  no  food  should  be  allowed  for  three  hours,  only  a  little 
ice  being  given  to  suck.  For  the  first  forty-eight  hours  diluted  milk 
or  barley-water  only  should  be  allowed,  nutrient  enemas  being  gi\'en 
if  needful;  all  feeding  is  done  with  a  spoon;  the  child  is  weaned.  After 
this  yolks  of  eggs,  arrowroot,  broths,  soups,  and,  in  about  ten  days, 
light  food  of  other  kinds  if  the  child  is  old  enough.  The  hands  should 
be  secured  for  the  first  few  days.  If  the  patient's  temper  and  intelligence 
allow  it,  the  mouth  may  be  regularly  washed  with  boric  acid  or  salt 
solution.  In  any  other  case  it  is  best  to  leave  the  wound  quite  alone. 
The  nurse  should  devote  herself  to  preventing  the  child  from  crying  and 
to  keeping  the  patient  amused.  Whenever  it  is  possible,  the  child  should 
be  taken  into  the  fresh  air  after  the  first  two  or  three  days.  "There 
should  be  no  hurry  to  remove  the  sutures,  which,  if  not  of  silk,  may 
remain  for  seven  or  ten  days  in  the  soft,  and  an  almost  indefinite  time 
in  the  hard,  palate.  No  one  should  be  allowed  to  look  at  them  either 
early  or  often.  It  is  well  for  the  operator  to  keep  out  of  the  child's 
notice  for  the  first  ten  days."  It  is  now  a  well-established  custom,  in 
America  at  least,  to  operate  these  infants  within  the  first  six  months, 
as  soon  as  the  child  has  a  hold  on  life. 


366  OPERATIONS   ON   THE   MOUTH,    NOSE,    AND    PHARYNX 

"To  make  this  subject  of  after-treatment  at  all  complete  a  few  words 
must  be  said  about  the  improvement  of  speech  after  the  cleft  has  been  sur- 
gically cured,  and  the  occasional  need  of  an  obturator.  Even  after  a  com- 
plete closure  of  the  cleft  much  awkwardness  of  speech  is  liable  to  remain, 
this  being,  of  course,  most  marked  the  older  the  patient  is.  Parents  are  often 
greatly  to  blame  for  the  little  trouble  they  will  take  to  further  the  success  of 
the  surgeon's  efforts,  and  this  refers  in  many  cases  to  those  who  have  not  the 
excuse  of  ignorance  and  toilsome  life  of  the  poorer  classes.  They  too  often 
act  as  if,  because  the  cleft  is  closed,  no  further  responsibility  rests  with  them. 
Again,  the  patients  being  usually  children,  without  thought  as  to  the  future, 
and  satisfied  with  the  improvement  in  their  deglutition,  present  many  diffi- 
culties. Not  only  has  the  child  to  be  taught  the  right  way  of  using  its  organs 
of  speech,  but  wrong  habits,  especially  nasal  and  guttural  tones,  have  to  be 
unlearned.  This  is  only  to  be  brought  about  by  means  of  systematic  lessons 
and  practice  gone  through  regularly  day  by  day  for  months  and  even  years. 
No  plan  will  be  found  better  than  that  recommended  by  Mr.  W.  Haward, 
Clin.  Lect.,  'On  Some  Forms  of  Defective  Speech.''  The  instructor  should 
sit  directly  facing  the  pupil;  the  pupil  is  made  to  fix  his  attention  thoroughly 
upon  the  face  of  the  teacher,  and  to  copy  slowly  his  method  of  articulation. 
This  should  be  displayed  by  the  teacher  in  an  exaggerated  degree,  every 
movement  of  the  lips  and  tongue  being  made  as  obvious  as  possible  to  the 
pupil,  and  the  more  difficult  sounds  or  movements  prolonged  for  the  purpose. 
Thus,  for  instance,  suppose  the  word  'sister'  were  to  be  practised,  the  teacher, 
having  filled  his  chest  with  a  long  inspiration,  would  open  his  Hps  and  draw 
back  the  angles  of  the  mouth,  so  that  the  pupil  could  see  well  the  position  of 
the  tongue  against  the  teeth;  he  could  then  prolong  the  hissing  sound  of  the 
's'  and,  finally,  separating  the  teeth  as  the  sound  of  the  't'  in  the  second  syl- 
lable issues,  allow  the  pupil  again  to  see  the  position  of  the  tongue  as  the  word 
is  ended.  Or,  for  another  example,  take  the  word  'lily.'  Here  the  teacher 
would  separate  the  lips  and  teeth,  so  that  the  tongue  would  be  seen  curved 
upward,  with  the  tip  touching  the  hard  palate;  the  word  would  then  be  pro- 
nounced with  a  prolongation  of  each  syllable,  the  teeth  and  lips  being  kept 
open,  so  that  the  uncurling  of  the  tongue  and  its  downward  movement  are 
clearly  seen.  So,  again,  in  teaching  the  proper  method  of  sounding  such 
words  as  'wing'  or  'youth,'  much  aid  is  given  by  keeping  the  lips  somewhat 
separated,  so  that  the  relation  of  the  tongue  and  palate  can  be  made  manifest. 
The  pupil  must  be  made  to  fill  his  chest,^  and  then  to  imitate  as  closely  as 
possible  every  movement  and  sound  of  the  teacher;  and  this  may  sometimes 
be  assisted  by  making  the  pupil  feel  with  the  finger  as  well  as  observe  with 
the  eye  the  relative  movement  and  position  of  the  teacher's  tongue  and  pal- 
ate.    There  should  be  no  other  person  in  the  room  to  distract  the  pupil's  atten- 

^  Lancet,  1883,  i,  iii. 

^  Opening  the  mouth  widely  and  learning  to  keep  the  tongue  down  on  the  floor  of  the 
mouth  are  two  points  to  be  early  and  strenuously  insisted  upon.  The  patient  should  prac- 
tise them  before  a  looking-glass. 


EXCISION    OF   THE    TONGUE,    PARTIAL   OR   COMPLETE  367 

tion.  It  is  best  to  continue  the  exercise  for  a  short  time  only,  and  to  repeat  it 
frequently,  rather  than  fatigue  the  child  by  a  long  lesson;  and  it  is  a  good  plan 
to  take  an  ordinary  elementary  speUing-book  and  to  mark  the  words  which 
the  pupil  finds  most  diificult  to  pronounce,'  so  that  these  may  be  especially 
practised. 

"With  regard  to  the  question  of  obturators  and  vela,  in  cases  where  it  has 
been  found  impossible  to  close  a  very  wide  cleft,  or  where  it  is  evident  that  even 
after  a  successful  operation  the  palate  will  be  so  tense  and  short  as  to  be 
quite  unable  to  touch  the  pharynx,  and  so  shut  off  the  nose  from  the  mouth, 
an  obturator  may  be  required."^ 

This  matter  should  be  referred  to  a  dental  surgeon  of  experience. 

Complications  and  Sequelae. — (i)  Vomiting,  if  excessive  or 
if  by  chance  something  solid  comes  up,  may  cause  the  wound  to  separate 
and  the  operation  to  fail. 

(2)  Tension  may  cause  sutures  to  cut  through  and  let  the  wound 
separate.  The  only  treatment  of  this  naturally  is  preventive,  and  is, 
therefore,  a  matter  to  be  considered  at  the  operation. 

(3)  Hemorrhage  after  operation  is  very  rare  in  children,  but  must  be 
watched  for  in  adults. 

(4)  Sepsis,  curiously  enough,  merely  from  mouth  bacteria,  may  be 
disregarded,  but  infections  of  such  nature  as  arise  from  scarlet  fever, 
measles,  or  diphtheria  are  serious,  and  will  usually  result  in  at  least 
partial  failure  of  the  operation.  At  the  slightest  appearance  of  a  suspici- 
ous membrane  in  the  mouth  diphtheritic  antitoxin  should  be  given,  even 
before  a  bacteriologic  report  can  be  obtained. 

(5)  Diarrhea. — This  complication  may  appear  as  a  part  of  the 
shock  of  operation  or  it  may  be  due  to  any  of  the  usual  causes.  The 
bowels  should  be  cleaned  out  with  small  doses  of  calomel  or  with  castor 
oil,  and  the  food  should  be  modified  and  sterilized  according  to  the  age 
and  condition  of  the  patient. 

For  a  masterly  article  on  Cleft-palate  and  Hare-lip  the  reader  is 
referred  to  a  monograph  under  that  title  by  W.  Arbuthnot  Lane,  M.S., 
F.R.C.S.,  of  Guy's  Hospital,  published  ^  in  I-ondon  in  1908. 

EXCISION  OF  THE  TONGUE,  PARTIAL  OR  COMPLETE 

The  chief  problems  which  arise  after  this  operation  are,  to  keep 
the  mouth  clean  and  to  nourish  the  patient.  The  practice  of  Jacobson  * 
before  this  operation  is  excellent.     He  teaches  the  patient  to  wash  the 

^  Especially  those  containing  the  letters  t,  b,  d,  k,  g,  s,  z,  and  1  (Rose). 
^  Jacobson  and  Steward,  The  Operations  of  Surgery,  1902,  i,  444,  445. 
^  Med.  Pub.  Co.,  Limited.  *  Loc.  ciL,  p.  467. 


368  OPERATIONS    ON    THE    MOUTH,    NOSE,    AND    PHARYNX 

mouth  thoroughly  with  some  antiseptic,  such  as  carbohc  acid  i :  80, 
boric  acid,  or  some  of  the  alkahne  antiseptics.  The  patient  also  "gets 
used  to  feeding  himself  with  a  drainage-tube  attached  to  a  feeder  spout 
and  passed  by  himself  to  the  back  of  his  throat." 

At  the  completion  of  the  operation  the  cut  surface  is  painted  with 
compound  tincture  of  benzoin  or  a  solution  of  zinc  chlorid  (gr.  x-gj). 
The  patient  is  given  ice  to  suck,  and  nourishment  is  given  as  necessary 
in  liquid  form  through  nutritive  enema.  If  the  patient  has  learned  how 
beforehand,  he  will  be  able,  after  the  usual  post-ether  nausea  has  passed, 
to  feed  himself  by  the  feeder-tube  passed  to  the  back  of  his  throat.  The 
mouth  and  wound  must  be  inspected  and  thoroughly  cleaned  at  least 
every  three  hours  during  the  daytime.  The  patient  must  be  made  to  sit 
up  as  soon  as  possible  and  his  position  must  be  continually  altered. 

Complications  and  Sequelae. — (i)  Bronchopneumonia  and  lobar 
pneumonia  are  the  great  causes  of  failure  after  this  operation,  the  former 
due  to  direct  inhalation  of  infected  material.  Care  of  the  mouth,  the 
sitting  posture,  and  general  early  activity  are  the  preventive  measures, 

(2)  Hemorrhage. — Early  hemorrhage  is  rare.  Secondary  hemor- 
rhage is  unusual  if  the  mouth  has  been  kept  clean.  Arterial  bleeding 
in  the  conscious  patient  can  only  be  controlled  by  the  immediate  applica- 
tion of  hemostatic  forceps  and  all  the  patient's  courage  will  be  necessary 
to  endure  their  remaining  in  situ. 

(3)  Edema  of  the  glottis  may  follow  during  any  of  the  first  days  from 
extension  of  infection,  and  must  be  met  by  scarification,  intubation,  or 
tracheotomy. 

(4)  Suffocation  may  be  caused  by  the  stump  of  the  tongue  falling 
back  against  the  epiglottis.  This  is  so  liable  to  occur  that  it  is  probably 
best  always,  at  the  end  of  the  operation,  to  leave  a  stout  silk  loop  sewed 
through  the  stump  hanging  2  or  3  in.  out  of  the  mouth. 

RANULA 

"In  operating  for  the  relief  of  ranula  the  object  to  be  attained  is 
either  to  establish  a  new  communication  between  some  portion  of  the 
ducts  of  the  sublingual  glands  involved  and  the  cavity  of  the  mouth  or 
the  complete  removal  of  the  entire  gland.  The  simplest  method  to  re- 
establish a  connection  betAveen  the  ducts  of  the  gland  and  the  cavity 
of  the  mouth  is  through  the  use  of  a  seton.  By  applying  a  large-sized 
silk  suture  transversely  across  the  ranula,  and  tying  this  loosely  so  that 
it  does  not  have  a  tendency  to  cut  away  the  intervening  portion  of  the 
mucous  membrane,  one  can  frequently  secure  the  growth  of  epithelial 
cells  in  these  openings  and  the  cavity  of  the  mouth  becomes  continuous. 


ALVEOLAR    ABSCESS  369 

After  this  has  occurred,  at  both  the  point  of  entrance  and  exit  of  the 
suture  a  new  suture  may  be  introduced  through  the  same  openings  and 
tied  more  tightly,  so  that  the  intervening  tissue  may  become  absorbed 
slowly.  The  opening  formed  between  the  cavity  of  the  ranula  and 
the  mouth  will  thus  become  continuously  lined  with  mucous  membrane 
and  presently  a  permanent  opening  will  be  established.  This,  however, 
will  not  occur  in  every  case,  and  it  may  become  necessary,  later,  to  remove 
a  considerable  portion  of  the  tissue  between  the  cavity  of  the  mouth 
and  the  ranula."  ^ 

In  my  experience  the  silk  seton  through  both  sides  of  the  tumor  gets 
foul  from  mouth  contents  and  secretions,  induces  inflarmnation,  and 
tends  to  cut  itself  too  rapidly  to  establish  a  permanent  duct  or  ducts. 
Better  than  silk,  therefore,  is  an  ellipse  of  silver  wire,  or,  better  still, 
because  it  is  stiffer,  gold  wire,  may  be  used.  A  piece  of  gold  wire  is 
passed  through  and  bent  into  the  shape  of  an  ellipse  and  the  ends  need 
not  be  twisted.  Motion  of  the  tongue  moves  the  wire  enough  to  establish 
openings,  but  does  not  cause  the  wire  to  cut  through. 

ALVEOLAR  ABSCESS 

Incisions  of  the  gum  tend  to  close  rapidly.  Closure  may  be  delayed 
by  means  of  iodoform  wick  or  packing,  which  is  rarely  indicated,  or 
by  the  simple  procedure  of  dipping  the  knife-blade  in  95  per  cent, 
carbolic.  Ordinarily,  syringing  or  irrigating  is  never  required  unless 
there  is  present  septic  periostitis  or  osteomyelitis  (hydrogen  dioxid 
should  not  be  used).  If  the  constitutional  symptoms  persist,  these  are 
to  be  thought  of  as  well  as  empyema  of  the  antrum  of  Highmore. 

If  the  incision  is  within  the  mouth,  as  it  should  he  whenever  possible, 
the  patient  should  be  supplied  with  some  pleasant  mild  antiseptic,  such 
as  liquor  sodii  boratis  compositus  (Dobell's  solution)  or  liquor  anti- 
septicus  alkalinus,  and  instructed  to  rinse  the  mouth  out  e^■ery  two 
hours,  at  the  same  time  exerting  gentle  pressure  on  the  cheek  over  the 
tumor  to  assist  in  drainage.  Lying  on  a  hard  pillow  upon  the  affected 
side  will  act  similarly.  With  these  precautions  it  will  very  rarely  be 
necessary  to  reopen  an  abscess. 

The  tooth  which  gives  origin  to  the  abscess  can  usually  be  determined 
by  tenderness  elicited  by  pressure  on  its  crown.  If  it  is  in  bad  shape, 
it  should  be  removed.  If  the  dentist  advises,  it  should  be  sterilized  and 
filled,  if  necessary. 

In  case  of  a  sinus  through  the  check,  which  heals  with  a  disfiguring 
scar,  a  tenotome  should  be  passed  under  the  scar  to  separate  it  from 

^  Ochsner,  Clin.  Surg.,  iqo2,  p.  318. 
24 


37° 


OPERATIONS    ON    THE    MOUTH,    NOSE,    AND    PHARYNX 


the  underlying  bone  or  tissue,  and  paraflBn  injected  to  restore  the  contour 
of  the  face.  Long-standing  sinuses — internal  or  external — usually  speak 
for  a  sequestrum.  If  internal,  the  dentist  can  usually  relieve  them.  If 
external,  the  source  of  the  discharge  is  Hkely  to  be  in  the  maxilla  itself, 
and  radical  measures  should  be  taken  to  remove  necrotic  bone. 

PARAFFIN  PROSTHESIS  FOR  DEFORMITY  OF  THE  NOSE  AND 

OTHER  PARTS 

The  danger  most  feared  in  this  procedure,  particularly  if  the  paraflSn 
be  used  hot,  is  the  irmnediate  one  of  embolism,  followed  by  thrombosis 
of  the  ophthalmic  vein,  with  consequent  blindness.  Nevertheless,  in 
all  the  literature  there  are  only  three  cases.^  This  possibility  should 
always  be  considered  when  advising  this  operation.     When  the  calamity 


Fig.  io8. — Paraffin  Prosthesis. 
Deformity  resulting  from  abscess  of  septum;  before 


Fig.   109.- 


-Paraffin  Prosthesis  After    Treat- 
ment. 


occurs,  there  is  no  treatment.  When  cold  paraffin  (melting  at  115°  F.) 
is  used,  however,  screwed  in  by  the  ingenious  syringe  of  Dr.  Beck,  as 
modified  by  V.  Mueller  &  Co.,  of  Chicago,  the  danger  is  at  a  minimum 
— so  small  that  I  do  not  hesitate  to  advise  the  operation  in  cases  of 
notable  deformity. 

After  the  injection  the  injected  mass  is  molded  into  the  desired 
shape  and  a  compress,  wrung  out  in  iced  witch-hazel,  laid  over  the  nose 
at  intervals  for  the  first  ^venty-four  hours  or  longer.  There  is  some 
reaction  in  the  way  of  .swelling  and  tenderness  which,  unless  true  sepsis 
develops,  should  subside  after  forty-eight  hours.     If  the  wound  or  the 


^  Harmon  Smith,  Laryngoscope,  St.  Louis,  1908,  xviii, 


NASAL  POLYPI  AND  SPURS  .371 

paraffin  cavity  becomes  infected,  as  a  rule,  it  will  not  heal  until  the  last 
bit  of  paraffin  is  either  forced  or  curetted  out.  The  operation  should 
not  then  be  attempted  again  for  at  least  three  months. 

Sometimes  this  method  leaves  an  obvious  foreign  body  which  is 
more  noticeable  than  the  original  deformity.  On  this  account  the 
procedure  should  not  be  used  unless  there  is  a  definite  and  serious  cos- 
metic indication.^ 

NASAL  POLYPI  AND  SPURS 

Adhesions. — Special  care  should  be  observed  in  operating  within 
the  nose  to  prevent  adhesions,  which  are  the  result  of  two  wounded  sur- 
faces coming  into  apposition.  This  condition  may  occur  after  the  most 
painstaking  technique,  on  account  of  the  extreme  narrowness  of  the  nasal 
chamber.  The  nose  should  be  examined  by  the  surgeon  daily,  and  any 
tendency  to  adhesions  carefully  noted  and  the  apposing  surfaces  sepa- 
rated with  the  nasal  probe.  After  drying  the  surfaces  collodion  may  be 
painted  on  and  aristol  blown  over  the  raw  mucous  membrane.  In  some 
cases  a  strip  of  gauze,  covered  with  thin  rubber  dam,  may  be  laid  between 
the  septum  and  the  turbinate,  or  an  intranasal  tampon,  made  from 
Bernay's  sponge,  may  be  found  of  great  service.  This  dressing  should 
be  changed  daily  until  heahng  has  taken  place.  If  possible,  packing 
in  the  nose  after  an  intranasal  operation  is  to  be  avoided,  as  it  has  a 
tendency  to  check  the  natural  drainage  and  favor  sepsis.  It  is  advisable 
to  place  in  the  vestibule  of  the  operated  side  a  small  plug  of  aseptic 
absorbent  cotton,  thereby  protecting  the  wound  from  impurities  from 
the  atmosphere.  This  may  be  changed  from  time  to  time  and  left  out 
altogether  after  twelve  hours.  It  is  preferable  not  to  use  washes  in  the 
nasal  chambers  for  several  hours  after  an  operation,  as  bleeding  is  sure 
to  follow  from  disturbance  of  the  cut  surface  by  dislodging  of  clots. 
At  the  end  of  twelve  hours  Dobell's  solution,  or  liquor  antisepticus 
alkalinus,  may  be  used,  diluted  one-half  with  warm  water. 

Nasal  Hemorrhag"e. — This  is  a  frequent  after-result  of  intra- 
nasal surgery.  It  is  always  advisable  to  define  clearly  the  location 
from  v/hich  the  bleeding  arises,  whenever  this  is  possible,  and  not  to 
pack  the  nose  except  as  a  last  resort.  Cold  towels  should  be  applied 
externally,  and  cracked  ice  may  be  used  in  the  mouth  and  several  small 
pieces  placed  in  the  nose.  Absolute  rest  should  be  insisted  upon  and 
all  coughing  and  sneezing  avoided.  If  simple  measures  do  not  stop  the 
bleeding,  the  nose  may  be  packed  with  sterilized  gauze  soaked  in  ad- 
renalin, or  a  cigarette  pack  made  with  sterilized  cotton  or  gauze,  with 

^  F.  Strange  Kolle,  Subcutaneous  Hydrocarbon  Prostheses,  New  York,  1908. 


372-  OPERATIONS    OX    THE    MOUTH,    NOSE,    AND    PHARYNX 

a  thin  dental  rubber  layer  outside  to  prevent,  temporarily,  adherence  to 
the  mucous  membrane.  In  most  cases  it  is  only  necessary  to  pack 
either  the  anterior  or  middle  portions  of  the  nose,  but  in  a  few  excep- 
tional cases  it  is  necessary  to  pack  the  posterior  cavity.  This  may  be 
best  done  after  so  shrinking  the  turbinates  with  a  4  per  cent,  cocain  in 
1 :  1000  adrenalin  solution,  so  that  as  much  room  as  is  possible  may  be 
gained  to  allow  thorough  and  careful  work.  Several  long  strips  of 
sterilized  gauze  are  carried  backward,  through  the  anterior  nares,  with 
Hartman's  long-bladed  nasal  forceps,  to  the  posterior  space  (where 
it  is  advisable  to  have  the  finger  as  a  guide  to  pre\'ent  the  packing  coming 
in  contact  with  the  pharyngeal  wall)  and  the  nostril  is  firmly  filled  with 
the  gauze.  This  packing  should  not  be  allowed  to  remain  in  the  nose  for 
a  longer  period  than  t^\'enty-four  to  forty-eight  hours.  In  removing 
the  packing  great  care  should  be  exercised  to  prevent  renewed  bleeding. 
If  rubber  dam  or  Cargile  membrane  has  been  used,  there  is  no  tendency 
for  the  shreds  of  gauze  to  adhere  to  the  mucous  membrane.  With  the 
plain  gauze  dressing  it  should  be  thoroughly  wet  with  dioxid  of  hydrogen 
and  removed  slowly  and  carefully. 

Packing  the  postnasal  space  is  undesirable  on  account  of  possible 
sepsis  or  infection  of  the  middle  ear  through  the  Eustachian  tubes.  If 
hemorrhage  demand  such  a  procedure,  it  is  best  done,  not  by  means  of 
Bellocq's  cannula,  but  by  passing  a  soft-rubber  catheter  through  the  nose 
and  into  the  mouth,  and  tying  to  this  one  end  of  a  piece  of  suture  material, 
to  which  a  tampon  is  attached.  This  is  drawn  through  the  nose  and 
the  tampon  rests  in  the  postnasal  space.  The  other  end  of  the  suture 
material  comes  out  of  the  mouth  and  is  tied  to  the  nasal  end  and  rests 
over  the  ear.  The  nares  is  packed  anteriorly  if  necessary.  This  plug 
should  not  remain  in  situ  longer  than  t^venty-four  hours,  and,  after 
removing,  the  parts  should  be  cleansed  with  Dobell's  solution  diluted 
to  one-half  strength. 

ANTRUM  OF  HIGHMORE 

After  a  radical  antrum  operation  (opening  both  through  canine 
fossa  and  lower  meatus)  the  gauze  may  remain  in  place  for  forty-eight 
hours,  and  be  then  removed  and  the  antrum  washed  out  by  a  glass 
syringe  and  rubber  tube  or  catheter  passed  into  mouth  wound,  the  wash 
coming  out  through  the  nose.  Dobell's  solution,  one-half  strength, 
some  other  alkaline  preparation,  or  normal  saline  solution  may  be  used. 
This  procedure  should  be  repeated  daily  until  no  trace  of  pus  can  be 
seen.  After  one  week  the  cavity  should  be  inspected  and  probed  to 
find  if  any  areas  of  diseased  mucous  membrane  or  carious  bone  exist. 
If  it  is  desirable  to  allow  the  wound  in  the  mouth  to  remain  open,  it 


REMOVAL    OF    ADENOIDS  373 

should  be  repacked  and  the  wick  changed  every  second  day.     When 

the  mouth  wound  closes,  the  washing,  if  more  is  necessary,  is  done 

through  the  inferior  meatus.     If  necrotic  areas  of  bone  are  found,  they 

should  be  gently  curetted,  after  applying  5  per  cent,  cocain  in  i :  1000 

adrenalin  solution,  and  then  touched  with  50  per  cent,  silver  nitrate 

solution.      Any  associated  or  secondary  atrophic  rhinitis  or  polypoid 

condition  of  the  nose  must  be  coincidentally  treated. 

Destruction  or  injury  of  the  superior  dental  nerve,  with  resulting 

death  of  three  or  more  teeth,  should  not  occur  after  a  careful  operation, 

unless  there  be  an  anomaly  in  the  situation  of  the  nerve  with  relation  to 

the  canine  fossa. 

FRONTAL  SINUS 

Cold  compresses  should  be  applied  constantly  to  lessen  postoperative 
edema  and  ecchymosis.  External  dressings  should  be  changed  in 
twenty-four  hours  and  the  covered  eye  bathed  with  saturated  solution 
of  boric  acid.  The  drainage-tube  should  be  left  in  position  for  forty- 
eight  hours,  and  after  its  removal  the  sinus  should  be  syringed  with 
Dobell's  solution,  one-half  strength.  The  tube  should  be  replaced  and 
the  treatment  repeated  daily  for  two  weeks.  After  this,  if  the  pus  has 
disappeared,  the  tube  may  be  left  out.  If  necessary,  a  silver  tube  may 
be  used,  which  should  be  w^orn  until  every  trace  of  discharge  has  ceased. 
If  the  sinus  has  not  been  packed,  it  may  be  washed  out  in  twenty-four 
hours  with  warm  normal  saline  solution  or  saturated  solution  of  boric 
acid. 

For  some  time  patients  may  complain  of  diplopia  if  the  pulley  of 
the  superior  oblique  muscle  has  been  interfered  with.  This  gradually 
passes  off  in  a  week. 

A  certain  amount  of  numbness  on  the  forehead  upon  the  affected 
side  may  occur.     This  also  disappears  in  a  short  time. 

The  discharge  may  cease  in  a  few  weeks,  or  it  may  take  months  to 
complete  the  cure.  If  unsightly  scars  or  depressions  persist,  parafihn 
prosthesis  may  be  employed. 

REMOVAL  OF  ADENOIDS 
The  patient  should  be  made  to  lie  on  the  side,  and  should  be  care- 
fully watched  for  the  vomiting  of  blood,  which  is  sure  to  occur.  Should 
the  bleeding  be  excessive,  as  it  may  be  if  the  curet  has  cut  into  the 
mucosa,  or  has  left  pieces  half  cut  off,  or  if  the  child  is  a  bleeder,  or  if 
the  growth  is  malignant,  the  patient  should  be  sat  up  and  an  applica- 
tion of  1 :  1000  adrenalin  solution  made  to  the  site  of  operation.  If 
three  or  four  applications  of  this  do  not  stop  the  bleeding,  a  tampon  of 


374  OPERATIONS    ON   THE  MOUTH,    NOSE,    AND   PHARYNX 

gauze,  with  a  piece  of  silk  tied  around  the  middle,  may  be  prepared,  a 
nasal  forceps  passed  through  an  anterior  nares,  the  mouth-gag  placed 
in  position,  the  silk  attachment  on  the  tampon  passed  with  the  finger 
into  the  postnasal  space,  seized  then  by  the  nasal  forceps,  and  the  silk 
drawn  out  through  the  nose,  thus  bringing  a  tampon  of  appropriate  size 
into  full  pressure  in  the  postnasal  space.  Monsell's  solution  is  another 
styptic  which  may  be  used. 

Occasional  oozing,  small  in  amount,  may  continue  so  long  that,  at 
the  end  of  ten  or  twelve  hours,  the  child  is  largely  exsanguinated.  For 
this  the  nurse  must  be  on  the  watch,  and  measures  such  as  those  given 
are  then  to  be  taken.  Many  instances  of  death  from  particles  of  adenoid 
tissue  or  blood  in  the  trachea  have  been  noted,  though,  perhaps  naturally, 
few  have  been  reported.^ 

The  patient  should  be  in  bed  one  to  three  days,  or  longer  if  there  is 
fever,  and  should  not  go  out-of-doors  in  wet  or  very  cold  weather  within 
a  week  after  the  operation. 

Ice-cream  and  cracked  ice  relieve  pain,  and  a  mild  embrocation, 
such  as  oleum  gaultheria;  and  linimentum  saponis,  equal  parts,  may  be 
applied  to  the  muscles  of  the  neck  if  stiffness  occurs.  A  laxative  should 
be  given  twenty-four  hours  after  the  operation,  to  clear  the  stomach  and 
bowels  of  any  blood  that  may  have  been  swallowed  and  not  expelled 
from  the  stomach  by  vomiting.  The  diet  should  be  limited  for  the  first 
twenty-four  hours  to  cold  liquids  or  semisolids.  Eisenzucker  tablets 
(saccharated  red  oxid  of  iron)  of  3-  or  5-gr.  doses  are  agreeable  to  children, 
and  should  be  used  when  anemia  exists. 

Nasal  obstruction  in  many  cases  seems  greater  for  a  few  days  than 
before  operation,  due  to  the  swelling  and  inflammation  of  the  naso- 
pharynx. Nose-breathing  should  improve  in  from  four  to  seven  days, 
but  the  vicious  habit  of  mouth-breathing,  especially  in  older  children, 
can  be  corrected  only  by  repeated  admonition,  which  almost  amounts 
to  ''nagging,"  during  the  day,  and  possibly  by  the  use  of  a  four-tailed 
chin  bandage  to  hold  the  mouth  shut  at  night. 

Complications  and  Sequelae. — (i)  Bronchopneumonia  from  in- 
halation of  blood  or  vomitus. 

(2)  Sepsis,  shown  by  excessive  purulent  excretion  and  possibly  by 
general  symptoms.  This  is  best  treated  by  irrigation  through  the  nose 
into  the  mouth  with  some  alkaline  antiseptic,  such  as  Dobell's  solution, 
half  strength,  liquor  antisepticus  alkalinus,  or  normal  salt  solution. 

(3)  Earache,  due  probably  to  infection  through  the  Eustachian  tube, 
either  directly  during  operation  or  by  unwise  use  of  the  nasal  douche. 

^  Jacobson  and  Steward,  i,  372. 


REMOVAL   OF   TONSILS  375 

This  is  less  likely  to  occur  if  the  fossae  of  Rosenmiiller  have  been  thor- 
oughly cleansed  out  with  the  finger  during  operation.  The  ice-bag  or 
hot  water  should  relieve  this  in  most  instances.  Paregoric  or  Dover's 
powder  will  best  relieve  severe  pain.  If  the  drum  membrane  bulges, 
paracentesis  should  be  done  early. 

In  some  cases  after  removal  of  the  adenoid  tissue  the  catarrhal  deaf- 
ness does  not  clear  up  without  treatment.  In  these  cases  a  few  Politzer 
inflations  are  necessary.  In  more  chronic  cases  the  turbinates  may 
require  cauterization,  either  with  the  actual  cautery  or  some  chemical 
cautery,  of  which  trichloracetic  acid  is  the  best. 

(4)  The  cervical  lymph-nodes  may  swell  and  become  painful.  They 
usually  do  not  suppurate,  and  the  condition  calls  for  no  treatment  beyond 
the  application  of  an  ice-bag  or  a  hot-water  bag  if  that  seems  more 
soothing. 

(5)  The  possibility  of  the  appearance  of  diphtheria  im.mediately 
after  operation  should  always  be  kept  in  mind. 

(6)  Deformities  of  the  chest  may  be  to  some  extent  overcome  in 
young  patients  by  proper  breathing,  gymnastics,  and  out-of-door  exer- 
cises, the  causal  condition  having  been  removed. 

(7)  A  thick,  stuffy,  and  nasal  quality  to  the  speech  may  remain  for 
som.e  time  after  the  operation,  especially  in  children  who  have  had  nasal 
obstruction  for  some  time.  This  may  be  overcome  by  lessons  in  proper 
voice  production. 

(8)  In  some  cases  a  mouthy  voice,  improperly  called  "nasal,"  may 

be  due  to  slight  temporary  paresis  of  the  muscles  of  the  palate,  brought 

about  by  their  being  stretched  at  the  time  of  operation.     This  usually 

quickly  disappears  and  the  voice  becomes  natural.     If  there  is  a  paretic 

condition  of  the  soft  palate,  small  doses  of  strychnin  and  cold  gargles 

should  be  tried. 

REMOVAL  OF  TONSILS 

The  same  general  directions  for  after-treatment  hold  as  for  adenoid 
operation;  cold  gargling  with  Dobell's  solution,  diluted  to  one-half 
strength,  is  indicated,  with  an  occasional  swab  of  iodin-glycerin  mix- 
ture (iodin,  15  gr.,  to  glycerin,  i  oz.)  two  to  six  times  daily.  If 
there  is  discomfort  or  pain  on  swallowing,  orthoform  powder  may  be 
blown  over  the  cut  surface  or  an  occasional  lozenge  of  orthoform  allowed 
to  melt  in  the  mouth. 

Hemorrhage. — If    persistent  oozing  occurs    (see    p.  8i),    or  if 

hemorrhage  comes  on  several  days  after  the  removal  of  the  tonsils,  and 

adrenalin  or  Monsell's  solution   fail  to  check  it,  the   tonsillar  fossae 

•  should  be  examined  carefully  with  a  strong  reflected  light,  and  the 


376  OPERATIONS    ON    THE    MOUTH,    NOSE,    AND    PHARYNX 

anterior  pillars  retracted  to  see  if  the  bleeding  point  can  be  detected. 
In  some  cases  the  base  of  the  tonsil  or  ragged  edges  of  tonsillar  tissue 
have  been  left,  and  after  a  thorough  removal  the  bleeding  ceases.  If 
a  bleeding  vessel  can  be  seen,  it  should  be  grasped  with  a  hemostatic 
forceps  and  a  suture  applied.  Sometimes  the  mere  twisting  of  the 
forceps  on  the  vessel  will  stop  the  bleeding.  If  these  measures  fail,  the 
tonsil  hemostat  may  be  used,  and,  as  a  last  resort,  the  pillars  of  the 


Fig.  1 10. — Instruments  for  Tonsillar  Hemorrhage. 
A ,  Mikulicz-Stoerk  tonsillar  clamp,  with  detachable  handles;  B  and  C,  needles  for  sewing  together  the  pillars 

(Yankauer). 

tonsil  may  be  sutured  together  (see  Fig.  no),  and  if  unsuccessful,  the 
external  carotid  must  be  tied. 

TUHORS  OF  THE  TONSIL 
If  the  removal  has  been  solely  through  the  mouth,  the  same  care  is 
taken  as  in  operation  on  the  tongue.  (Seep.  367.)  If,  in  addition,  there 
is  a  wound  in  the  neck,  with  drainage  from  the  pharynx,  drainage 
gauze  should  be  kept  in  not  more  than  twenty-four  hours,  after  which 
drainage  should  best  be  allowed  to  maintain  itself,  provided  the  wound 
is  kept  thoroughly  clean.  The  dressing  should  be  replaced  as  often 
as  it  is  wet;  the  skin  about  the  wound  should  be  painted  with  compound 
tincture  of  benzoin  to  preserve  it  from  maceration.  Feeding  should 
be  done  by  esophageal  tube  for  between  two  and  three  weeks.  "The 
patient's  feeding  himself  should  be  forbidden  as  long  as  any  attempt 
at  this  causes  choking  or  coughing,  owing  to  the  danger  of  fluids  enter- 
ing the  air-passages"  (Jacobson).  The  patient  should  be  up  and  out 
of  bed  as  soon  as  possible. 


RETROPHARYNGEAL   ABSCESS  .  377 

PERITONSILLAR  ABSCESS 

It  is  assumed  that  no  surgeon  will  be  content  with  mere  incision 
of  the  abscess  of  quinsy  sore-throat.  If,  through  the  incision,  the  ex- 
ploring linger  breaks  down  all  dividing  walls  and  all  cell-like  accessory 
cavities,  making  the  abscess  into  one,  drainage  will  take  care  of  itself. 
The  tip  of  a  glass  syringe  may  be  introduced  through  the  wound  every 
two  or  three  hours  after  ether  recovery,  and  the  cavity  thus  washed  out 
with  warm  myrrh  or  some  alkaline  antiseptic  solution.  This  should 
be  done  for  twenty-four  to  seventy-two  hours,  only  when  the  patient  is 
awake.     Gargling  does  no  good  and  is  very  uncomfortable. 

The  patient  may  take  for  nourishment  whatever  he  can  swallow 
without  too  much  pain.  Usually  semisolids  at  room  temperature,  such 
as  mush,  blanc-mange,  curds,  and  jellies,  are  swallowed  the  easiest. 

Complications  and  Sequelae. — (i)  Septicopyemia  may  result 
in  patients  much  reduced  or  in  cases  inefficiently  opened.  Diphtheria 
may  be  present  coincidentally  or  may  appear  during  convalescence. 

(2)  Delayed  or  secondary  hemorrhage  should  never  occur,  unless 
due  to  anatomic  anomaly. 

RETROPHARYNGEAL  ABSCESS 

Most  of  these  cases  are  in  children  under  five  years  of  age.  It  is 
assumed  that  the  operation  has  been  a  vertical  pharyngeal  incision  on 
one  or  both  sides;  that  the  incision  has  been  very  free;  that,  as  in  the 
case  of  peritonsillar  abscess,  all  septa  have  been  broken  down  by  the 
finger;  that  the  operation  has  been  done  in  the  Rose  position. 

The  mouth  should  be  opened  wide  and  inspected  every  few  hours 
to  see  that  drainage  is  free;  that  the  wound  has  not  sealed  up  and  pus 
collected  within  it.  Washing  out  the  wound  is  not  necessary,  but  every 
effort  should  be  made  to  keep  the  mouth  thoroughly  clean. 

Complications  and  Sequelae. — Bronchitis  or  bronchopneu- 
monia make  the  commonest  complication.  The  most  important  treat- 
ment is,  naturally,  prevention  by  having  the  operation  done  in  such 
position  that  no  pus  is  inhaled  and  by  subsequent  mouth  cleanliness. 

Whether  acute  or  chronic,  retropharyngeal  abscess  is  extremely  likely 
to  cause  edema  of  the  glottis  and  suft'ocation.  An  ice-collar  is  a  good 
prophylactic  against  this  danger.  If  the  incision  is  made  through  the 
mouth  and  drainage  is  inefficient,  an.  external  incision  along  the  posterior 
border  of  the  sternomastoid  may  be  made. 

Septicopyemia  may  occur  and  generally  with  fatal  result.  The  usual 
general  treatment  applies.^     (See  Chapter  XXVI,  p.  250.) 

^  M.  A.  Goldstein,  The  Laryngoscope,  St.  Louis,  190S,  xviii,  46. 


CHAPTER  XLII 
OPERATIONS  ON  THE  NECK 

TRACHEOTOMY 

After  this  operation  the  patient  should  be  put  in  the  position  in 
which  he  can  breathe  best.  This  should  be  determined  by  experiment 
in  a  given  case.  Most  cases,  however,  breathe  best  reclining  at  about 
45°,  with  the  head  somewhat  back.  The  tape  which  holds  the  tube 
in  position  must  be  tight  enough  to  hold  in  the  tube  during  coughing, 
but  should  not  be  so  tight  as  to  constrict  the  neck,  for  this  not  only 
induces  the  natural  discomfort  of  venous  congestion  in  head  and  face, 
but  tends  to  cause  the  lower  end  of  the  tube  to  press  against  the 
inside  wall  of  the  trachea.  Some  patients  at  first  or  during  the  night 
may  find  relief  in  an  atmosphere  laden  with  hot-water  vapor  (so-called 
steam).  Where  the  coughing  is  continuous,  where  the  secretion  from 
the  tube  is  very  thick  and  stringy,  where  the  patient  continually  gets 
cyanotic,  in  spite  of  the  tube  being  clear,  steam  should  always  be  tried. 
For  the  purpose  of  confining  the  vapor,  any  of  the  usual  devices  for 
holding  mosquito-netting  over  the  bed  may  be  used,  or  a  special  one 
may  be  made  by  tying  four  uprights  to  the  legs  of  the  bed;  over  such 
uprights  a  sheet  is  dropped  as  a  canopy,  leaving  an  aperture  into  which 
the  vapor  may  be  carried  directly  from  the  mouth  of  the  tea-kettle 
over  an  oil-stove,  or  through  a  pipe,  a  steam  radiator,  or  any  other 
device  which  may  be  at  hand.  Such  apparatus  is  most  often  necessary 
where  intubation  has  failed  in  diphtheria  and  tracheotomy  has  been 
necessary. 

Ordinarily  the  room  should  be  kept  at  65°  to  70°  F.  Over  the 
mouth  of  the  tracheotomy-tube  should  be  placed  5  to  10  layers  of  gauze 
wet  with  boric  acid  or  some  such  mild  antiseptic.  This  wet  gauze 
serves  to  moisten  the  air  inspired,  and  to  make  it  less  irritating  to  the 
bronchi.  The  amount  of  gauze  should  not  be  enough  to  interfere 
with  free  breathing.  The  inner  tube  must  be  removed  and  cleaned  as 
often  as  necessary — probably  every  hour  or  t\vo  at  first.  A  solution  of 
sodium  bicarbonate  will  best  clean  the  secretions  off  the  tube,  though 
if  an  aluminum  tube  is  used,  it  must  not  be  washed  in  alkalis.     If  re- 

378 


TRACHEOTOMY  379 

mo\'ing  the  inner  tube  does  not  relieve  obstruction,  a  long,  narrow  feather 
(such  as  that  from  a  hen's  wing)  should  be  inserted  deep  into  the  outer 
tube  and  removed  with  a  t^visting  motion,  A  nurse  should  always  be 
present  and  waking  for  at  least  the  first  t\venty-four  hours  after  tracheot- 
omy. At  the  same  time,  it  should  be  remembered  that  the  care-taking, 
especially  cleaning  of  the  tube,  may  be  overdone,  just  enough  to  prevent 
the  child  getting  sleep,  the  most  important  remedy. 

Feeding  is  sometimes  a  difficult  problem.  As  after  all  operations, 
at  all  times,  unless  there  is  a  definite  reason,  these  cases  should  not  be 
wakened  for  feeding.  On  the  other  hand,  swallowing  at  first,  before 
the  patient  is  used  to  the  tube,  may  be  so  uncomfortable  that  it  is  difficult 
to  induce  the  patient  to  take  sufficient  nourishment.  Liquid  feeding 
through  the  mouth  should  be  tried.  If  it  fails,  nourishment  may  be 
carried  on  by  nutrient  enemas  or  by  esophageal  tube ;  the  latter  method 
is  so  apt  to  frighten  small  children  that  it  should  be  avoided  whenever 
possible.     (For  details  of  Esophageal  Feeding,  see  p.  129.) 

Removal  of  the  Tube. — In  general,  this  should  be  done  as  early 
as  possible.  Not  only  is  there  danger  of  ulceration  of  the  trachea  from 
pressure  of  the  inner  end  of  the  tube,  but  the  longer  the  person  uses  the 
tube,  the  more  difficult  is  it  for  him  to  resume  breathing  by  the  natural 
passages. 

"  Co7iditions  Which  Impede  the  Rejnoval  of  the  Tube. — (i)  Prolonged 
formation  of  membrane.  The  longest  possible  period  for  this  is  probably 
about  ten  days.  Patience  and  support  are  the  main  indications  in  the 
treatment  here.  (2)  The  larynx  is  crippled  like  any  other  inflamed 
part.  (3)  The  air-tube  is  closed  by  granulations,  usually  above  the 
cannula.  More  common  than  these  is  obstinate  swelling  of  the  mucous 
membrane.  Here  the  tube  must  be  removed  and  astringents  and 
caustics  carefully  applied  from  below,  with  the  aid  of  an  anesthetic  if 
necessary.  (4)  Closure  of  larynx  by  deep  ulceration  cicatrizing  after 
detachment  of  membrane.  In  such  a  case,  with  the  aid  of  an  anesthetic, 
the  larynx  must  be  opened  up  by  probes  of  increasing  size  and  laminaria 
tents  introduced  from  below,  and  later  on  by  the  use  of  MacE\^en's 
tubes.  (5)  Paralysis  of  the  dilating  cricoarytenoidei  postici  or  spas- 
modic action  of  the  closing  muscles,  arytenoidei  or  cricoarytenoidei 
lateralis,  from  fear,  excitement, -or  during  effort.^     (6)  The  commonest 

^  In  a  case  in  which  I  had  performed  tracheotomy,  and  was  watching  the  child 
for  the  first  few  hours  after  the  tube  had  been  dispensed  with,  most  urgent  symptoms 
came  on  during  the  slight  straining  which  accompanied  an  action  of  the  bowels,  the 
patient  falling  off  the  night-stool  onto  the  floor  apparently  lifeless.  Artificial  respiration 
restored  the  child,  and  the  case  did  well. 


380  OPERATIONS    ON   THE   NECK 

cause  of  inability  to  dispense  with  the  tube  is  probably  due  to  the  rapid- 
ity with  which  the  larynx  falls  into  abeyance  when  a  child  is  allowed 
to  breathe  through  a  tracheal  cannula,  the  patient  at  this  age  being  not 
intelligent  enough  to  understand  the  importance  of  dispensing  with  the 
tube,  and  perhaps  too  young  to  care  to  talk,  or,  if  older,  not  realizing 
the  need  of  again  using  its  voice  while  all  its  wants  are  supplied.  With 
the  above  condition  are  coupled  a  nervous  dread  of  having  the  tube 
removed  and  paroxysms  of  temper  and  struggling  which  rapidly  produce 
embarrassed  breathing.  Any  organic  mischief,  such  as  adhesions  in 
the  larynx,  is,  I  think,  extremely  rare,  and  granulations  above  or  below 
the  tube  are  more  often  talked  of  and  given  as  a  reason  for  inability  to 
dispense  with  the  tube  than  really  seen"  (Jacobson  and  Steward,  p. 
490).  Where  repeated  efforts  to  get  the  child  to  resume  natural  breath- 
ing fail,  the  O'Dwyer  cannula  should  be  inserted,  unless  there  is  organic 
obstruction  to  this  procedure.  The  O'Dwyer  tube  should  also  be 
removed  experimentally  every  day  or  two,  with  the  idea  of  dispensing 
with  it  as  soon  as  possible.  But  even  when  laryngeal  breathing  is 
restored  without  the  tube,  the  child  must  be  closely  watched,  especially 
at  night,  and  the  tube  inserted  at  a  moment's  need. 

Complications  and  Sequelae.— (i)  Hemorrhage.— Immedisite 
hemxorrhage  is  usually  venous,  the  result  of  the  congestion  of  asphyxia, 
and  stops  as  soon  as  breathing  is  well  established.  No  particular 
effort  need  be  made  to  stop  it.  Occasionally,  an  artery  in  the  thyroid 
isthmus  is  cut  and  must  be  tied.  Hemorrhage  after  some  days  may 
come  from  ulceration  of  the  trachea  from  pressure  of  the  tube;  pre- 
ventive measures  should  make  this  impossible.  The  tube  should  be 
only  long  enough  to  enter  the  trachea  and  curve  around  until  its  axis  is 
parallel  with  that  of  the  trachea.  A  tube  long  enough  to  reach  the 
sternal  notch  may  ulcerate  into  the  arch  of  the  aorta.  The  tube  should 
be  as  large  and  as  short  as  possible.  It  should  be  of  the  same  size 
throughout,  without  tapering.  The  inner  tube  should  project  a  little 
beyond  the  outer  one.  The  collar  of  the  tube  should  stand  out  as  little 
as  possible  from  the  neck. 

(2)  Sepsis  of  the  Wound. — Such  a  wound  is  never  entirely  aseptic. 
The  collar  of  the  tube  should  be  held  from  the  wound  by  a  few  layers 
of  gauze  split  to  straddle  the  tube.  The  wound  should  be  kept  sweet 
with  compound  tincture  of  benzoin,  eucalyptus  vaselin,  or  some  other 
antiseptic  emollient. 

(3)  Emphysema. — This  complication  is  usually  the  result  of  a  faulty 
operation.  Either  the  incision  in  the  trachea  is  not  in  the  same  plane 
with  that  in  the  soft  parts,  or  the  incision  in  the  trachea  is  too  small  for 


LARYNGOTOMY  381 

the  tube  and  immediate  efforts  at  breathing  pump  the  soft  tissues  full 
of  air.^ 

(4)  Ulceration  of  the  Trachea. — This  is  due  to  a  cannula  which  is 
too  long  or  which  has  a  wrong  curve.  This  condition  is  to  be  suspected 
if  the  expectoration  after  three  or  four  days  is  streaked  with  blood,  or  if 
the  outer  tube,  on  examination,  shows  a  black  patch  on  the  anterior 
aspect  of  the  lower  end.  If  the  tube  is  still  needed,  it  should  be  trimmed 
or  a  different  one  tried. 

(5)  Suppuration  may  rarely  take  place  in  the  mediastina.  This  is 
indicated  by  the  signs  and  symptoms  of  profound  torpidity,  labored 
breathing,  and  substernal  pressure  and  pain.  The  only  treatment  is  a 
well-performed  operation,  such  as  trephining  of  the  sternum. 

LARYNGOTOMY 

The  vertical  incision  in  the  pharynx  above  the  tube  should  be  left 
unsutured,  with  a  slight  packing  of  antiseptic  gauze  in  it.  The  foot  of 
the  bed  should  be  raised  for  the  first  t^venty-four  hours,  to  overcome  the 
tendency  of  the  drainage  to  run  down  into  the  trachea.  The  usual  care 
of  the  tracheotomy  tube  should  be  maintained.  (See  p.  378.)  Feeding 
should  be  carried  on  by  nutrient  enema  or  esophageal  tube  unless  the 
latter  is  particularly  painful  or  obnoxious  to  the  patient.  Solid  food 
should  be  taken  very  early,  since  it  frequently  may  be  well  taken  by 
natural  means  even  better  than  by  liquids.  The  sutures  holding  the 
end  of  the  trachea  and  of  pharynx  to  the  skin  must  be  removed  if  they 
are  non-absorbable  at  about  the  fifth  day,  as  they  tend  to  become  folded 
under  and  difficult  to  reach. 

The  question  of  a  permanent  apparatus  which  shall  serve  as  an 
artificial  pharynx  in  these  cases  is  a  complicated  and  special  one.  In 
general,  such  an  appliance  consists  of  two  arms,  one  going  down,  the 
other  up,  with  a  common  exit  at  the  site  of  the  operation  wound.  In 
such  a  tube  various  ingenious  valve-like  arrangements  are  provided  to 
allow  of  respiration  and  speech. 

^  Mr.  Jacobson  {loc.  cit.,  493)  quotes  the  conclusions  of  Dr.  Champneys  as  follows: 
(i)  "Emphysema  of  the  anterior  mediastinum,  often  associated  with  pneumothorax, 
occurs  in  a  certain  number  of  tracheotomies.  (2)  The  conditions  favoring  this  are  division 
of  the  deep  cervical  fascia,  obstruction  to  the  air-passages,  and  inspiratory  efforts.  (3) 
The  incision  in  the  deep  cervical  fascia  downward  should  not  be  longer  than  needful; 
it  should  on  no  account  be  raised  from  the  trachea,  especially  during  the  inspiratory  efforts. 
(4)  The  frequency  of  emphysema  probably  depends  much  on  the  skiU  of  the  operator, 
especially  in  inserting  the  tuVje.  (5)  The  dangerous  period  during  tracheotomy  is  the  in- 
terval between  the  division  of  the  deep  cervical  fascia  and  the  efiicient  introduction  of  the 
tube.  (6)  If  artificial  respiration  is  necessary,  the  tissues  should  be  kept  in  apposition  ■with 
the  trachea,  and  any  manipulations  performed  without  jerks. ' ' 


382  OPERATIONS   ON   THE   NECK 

Complications  and  Sequelae. — (i)  Shock  may  be  very  great, 
apparently  analogous  in  nature  to  that  frequently  seen  following  the 
slightest  laryngeal  operations.  (2)  The  usual  tracheotomy  dangers, 
with  relation  to  blocking  of  the  tube,  etc.,  exist.  (3)  Bronchopneumonia. 
This  danger,  due  to  inhalation  of  septic  matter,  blood,  and  food,  is  great, 
and  is  present  for  at  least  the  first  two  weeks.  (3)  Sepsis,  possibly 
extending  deep  into  the  neck  or  into  the  thorax,  can  be  met  only  by 
constant  care. 

INTUBATION;  INDICATIONS,  TECHNIQUE,  AFTER-TREATMENT 

When  laryngeal  stenosis  becomes  acute,  and  from  the  symptoms 
it  is  evident  that  the  patient's  life  is  in  danger  from  asphyxia,  immediate 
operative  relief  is  necessary.  In  such  cases  outside  of  a  hospital  tracheot- 
omy would  ordinarily  be  the  only  operative  procedure  possible.  In  a 
hospital  intubation  may  be  considered,  particularly  if  the  cause  is 
suspected  to  be  laryngeal  diphtheria,  or,  in  other  acute  cases,  if  some  one 
skilled  in  intubation  is  at  hand.  Where  there  is  no  immediate  urgency, 
intubation  may  be  chosen  if  the  patient's  condition  contraindicates  the 
shock  and  loss  of  blood  which  may  be  consequent  to  tracheotomy.  In 
the  case  of  gradually  increasing  obstruction  resulting  from  new-growth, 
tracheotomy  is  unquestionably  the  better  choice.  If  there  is  any  ques- 
tion of  aspirated  foreign  body  as  the  cause  of  obstruction,  intubation 
is  most  decidedly  to  be  avoided.  If  the  case  be  appropriate  for  either 
intubation  or  tracheotomy  on  the  grounds  as  stated,  and  the  patient  is 
an  adult,  the  difficulty  of  intubating  adults  would  incline  one  to  trache- 
otomy rather  than  intubation. 

In  the  operative  treatment  of  obstructive  laryngeal  diphtheria,  in 
hospitals  where  constant  supervision  by  nurses  and  physicians  ex- 
perienced in  the  technique  of  intubation  is  the  rule,  the  choice  between 
tracheotomy  and  intubation  would  ordinarily  be  in  favor  of  the  latter. 
The  statistics  since  the  advent  of  antitoxin  show  that  this  agent  has 
reduced  the  mortality  in  both  these  methods  of  procedure.  At  the 
South  Department,  Boston  City  Hospital,  the  intubation  mortality  for 
the  last  three  years  has  averaged  about  20  per  cent.  In  the  fever  hospitals 
of  London,  where  tracheotomy  is  the  operation  of  election,  the  mortality 
has  been  about  35  per  cent.  While  it  is  difficult  to  make  comparison 
of  cases  operated  in  different  countries,  the  consensus  of  opinion  in 
this  country,  based  on  statistics  of  mortality  and  experience  in  the  con- 
duct of  cases,  is  that  intubation  should  be  the  operation  of  election  in 
laryngeal  diphtheria. 

Under    the   following   conditions,    however,    tracheotomy    may    be 


intubation:  indications  383 

elected:  P^irst,  when  no  one  experienced  in  the  technique  of  intubation 
is  available;  second,  in  the  home,  where  constant  skilled  supervision  is 
impossible;  third,  in  the  case  of  some  adults  having  extensive  swell- 
ing of  tissues  of  the  neck,  when  experience  would  indicate  that  intuba- 
tion might  be  difficult  or  even  impossible.  Tracheotomy  becomes  the 
operation  of  necessity  in  any  case  w^hen,  for  one  reason  or  another, 
intubation  fails  to  relieve  or  when  the  tube  cannot  be  introduced  on 
account  of  the  stenosis. 

Indications  for  Operation  in  I^aryngeal  Stenosis. — 
There  are  all  grades  of  laryngeal  stenosis.  In  the  extreme  type  the 
symptoms  and  signs  are  so  obvious  and  urgent  that  relief  by  operative 
procedure  will  not  be  delayed.  The  patient  presents  a  picture  of  never- 
to-be-forgotten  agony  from  air-hunger.  He  tosses  about  in  the  bed  in 
vain  effort  to  obtain  sufficient  air.  The  skin  is  dusky  and  covered  with 
perspiration,  the  mouth  opened,  the  ala  nasi  dilating  and  contracting, 
the  sternocleidomastoid  muscles  in  a  state  of  spasm,  the  supraclavicular, 
substernal,  and  intercostal  tissues  retracted  at  each  attempt  at  inspira- 
tion. Expiration  is  quite  as  dijficult  as  inspiration,  and  the  abdominal 
muscles  become  hard  and  contracted  in  their  efforts  to  aid  the  diaphragm 
in  expelling  the  air  through  the  narrowed  larynx.  x\phonia  may  be 
complete  or  attempts  at  phonation  may  result  in  short,  high-pitched 
squeaks;  the  cough  as  commonly  heard  is  short,  rasping,  and  "croupy." 
Beyond  this  stage  of  cyanosis  there  is  apt  to  be  one  of  unconsciousness 
unless  operation  is  performed.  The  exertion  has  been  so  great  that  the 
heart  has  failed  and  we  have  a  state  of  pallid  asphyxia,  the  patient 
pulseless,  the  jaws  set,  and  the  musculature  generally  in  the  state  of 
spasm;  then  comes  relaxation,  and  death  rapidly  ensues.  If  the  patient 
is  first  seen  in  this  grave  condition,  intubation,  reinforced  by  hypodermic 
stimulation,  artificial  respiration,  and  oxygen,  will  often  cause  him  to 
regain  consciousness,  w'ith  eventual  recovery. 

Other  acute  conditions  besides  diphtheria  which  may  cause  sud- 
den stenosis  of  the  larynx  should  here  be  mentioned.  In  peritonsillar 
abscess  associated  with  extensive  swelling  edema  of  the  glottis  may  occur 
and  require  operative  interference.  The  same  may  be  said  of  severe 
t}^pes  of  tonsillitis.  Enlarged  cervical  glands  may  produce  constriction 
of  the  trachea  and  operative  relief  be  necessary.  In  the  latter  case 
tracheotomy  is  apt  to  be  indicated;  in  the  others,  intubation  should  be 
considered.  - 

Technique. — The  patient  should  be  wrapped  in  a  blanket  and 
taken  to  the  operating  room.  Here  there  should  be  laid  out  for  instant 
use  instruments  and  accessories  calculated  to  meet  any  emergency. 


384 


OPERATIONS    ON    THE    NECK 


Several  intubation  tubes  of  each  size  should  be  kept  attached  to  as 
many  introducers,  a  tracheotomy  set,  oxygen,  solutions  for  hypodermic 
stimulation,  and  a  sterile  syringe  should  be  at  hand. 

The  intubation"  instruments  follow  closely  in  their  design  those 
originated  and  perfected  by  O'Dwyer,  and  are  very  satisfactory  in  use. 
The  so-called  improvements  over  these  instruments  are  usually  the 
opposite.  The  tubes  are  of  metal,  either  nickel  or  gold-plated,  or  of 
rubber  molded  about  a  small  metal  tube.  The  metal  tubes  are  less 
fragile  than  the  rubber  and  are  consequently  more  commonly  used. 
The  rubber  tubes  are  preferable  in  cases  where  the  period  of  intuba- 


FiG.  III. — Operating-room,  Boston  City  Hospital,  South  Department. 
A,  Tubes  and  introducers  ready  for  use;  B,  tubes  in  cloth  holder,  with  obturators;  C,  gags;  D,  blanket, 
folded,  ready  to  be  opened  to  receive  patient;  E,  large  safety-pins  for  pinning  blanket  about  patient;  F,  stimu- 
lation tray  (in  case);  G,  sand-bag,  to  place  under  neck;  H,  gag  for  immediate  use. 

tion  is  for  one  reason  or  another  prolonged,  and  where  the  hea^7■  metal 
tube  might  eventually  produce  pressure  necrosis.  The  tubes  are  molded 
in  such  a  manner  as  to  produce  no  undue  pressure  at  any  point,  and  at 
the  same  time  are  equipped  with  a  flange  to  prevent  slipping  into  the 
larynx,  and  a  fusiform  enlargement,  at  about  the  middle,  in  order  that 
they  may  be  less  easily  expelled  from  the  larynx  when  the  patient  coughs. 
They  are  made  in  several  sizes  according  to  the  age  of  the  child  for 
which  they  are  intended.  Some  manufacturers  mark  on  each  tube 
the  limits  of  age  between  which  the  tube  is  applicable;  others  provide 
a  metal  scale  by  which  this  information  may  be  obtained.  The  common 
sizes  are  for  the  ages  of  one  to  t\vo  years,  two  to  four,  six  to  eight,  and 


intubation:  technique 


385 


ten  to  twelve,  and  several  adult  sizes,  the  latter  generally  of  rubber. 
Each  tube  has  extending  the  full  length  of  its  lumen  a  hinged  piece  of 


Fig.  112. — Instruments  for  Intubation. 
A,  Mouth-gag;  B,  introducer;  C,  tubes  and  obturators;  D,  extractor;  E,  tracheal  dilator. 

Tnetal  termed  the  obturator,  and  from  which  the  tube  is  easily  disengaged 
when  it  is  inserted  into  the  larynx.     This  obturator,  with  the  tube  upon 


Fig.  113. — Intubation. 

it,  fits  into  the  so-called  introducer,  which  is  merely  a  metal  handle  for 
the  manipulation  of  the  tube.  There  is  a  small  hole  drilled  through 
the  head  or  flange  of  each  tube,  through  which  a  loop  of  silk  thread  is 

25 


386 


OPERATIONS    ON    THE   NECK 


passed.  This  silk  loop  should  be  the  full  length  of  the  handle,  or  about 
6  inches. 

The  extractor  is  a  metal  instrument  with  a  tapered  and  curved  beak 
which  fits  into  the  lumen  of  the  head  of  the  tube,  and  when  the  beak  is 
expanded  by  pressing  the  lever,  the  tube  is  firmly  engaged  and  may  be 
extracted.  The  gag  may  be  seen  in  the  illustration.  Tubes  of  shorter 
dimension  than  those  described  are  often  useful  and  may  be  had  on 
special  order.  Others  with  a  built-up  flange  or  head  are  sometimes  use- 
ful where  there  is  much  edema  in  the  tissues  above  the  vocal  cords. 

The  patient  is  laid  upon  the  operating  table  and  is  wrapped  in  a 
blanket,  the  arms  held  to  the  side,  the  blanket  being  pinned  about  the 


1 14. — EXTUBATION. 


neck  and  over  the  body  tightly,  so  that  the  arms  and  legs  are  fixed. 
Underneath  the  neck  should  be  a  sand-bag.  The  back  of  the  head 
should  rest  near  the  edge  of  the  table.  The  table  should  be  heavy  and 
without  casters.  A  nurse  stands  at  the  patient's  left,  ready  to  restrain 
and  prevent  any  movement;  the  operator  stands  at  the  right,  and  at  the 
end  of  the  table  is  the  first  assistant,  who  is  to  steady  the  patient's  head 
and  hold  the  gag.  He  inserts  a  wooden  gag  between  the  teeth,  opens 
the  mouth  sufficiently  to  introduce  the  metal  gag,  and  with  this  widely 
separates  the  jaws.  The  plates  of  the  gag  should  be  wrapped  with 
adhesive  plaster  and  should  rest  on  the  molar  teeth.  The  introducer  is 
grasped  by  the  operator  in  his  right  hand,  the  silk  thread  is  passed  over 
his  little  finger,  and  his  thumb  is  ^jressed  against  the  upper  surface  of 


intubation:  after-treatment  387 

the  handle.  The  forefinger  of  his  left  hand  he  inserts  into  the  mouth, 
hooks  forward  the  epiglottis,  and  with  the  finger-tip  touches  the  vicinity 
of  the  right  arytenoid  cartilage.  The  back  of  the  finger  would  approxi- 
mate the  posterior  wall  of  the  pharynx,  and  the  side  of  the  finger  would 
be  about  on  a  line  with  the  vocal  cords.  In  the  brief  time  during  which 
the  finger  is  being  inserted,  the  introducer,  with  the  tube  affixed,  is  intro- 
duced into  the  mouth  in  the  median  line  and  the  end  of  the  tube  is  made 
to  follow  the  forefinger  as  a  guide.  The  end  of  the  tube  slides  over  the 
epiglottis,  and,  guided  by  the  forefinger,  reaches  its  tip  and  is  directed 
against  the  vocal  cords.  The  handle  of  the  tube  is  then  elevated  so  that 
it  is  in  a  vertical  position  or  slightly  beyond  vertical.  This  brings  the 
tube  about  in  a  fine  with  the  direction  of  the  larynx.  The  tube  should 
then  be  disengaged  by  the  forefinger,  and  thus  the  tube  is  loosened  from 
the  obturator.  The  tip  of  the  forefinger  on  the  head  of  the  tube  pushes 
it  gently  into  the  larynx,  at  the  same  time  releasing  the  tube  from  the 
obturator  The  introducer  is  removed  from  the  mouth,  and  at  the 
same  time,  by  means  of  the  forefinger,  the  tube  is  pushed  further  into 
the  larynx  until  the  head  is  well  seated. 

The  loop  of  silk  thread  is  carried  to  the  corner  of  the  mouth,  passed 
over  the  left  ear,  the  gag  removed,  and  the  patient  at  once  set  upright. 
If  the  tube  is  in  the  larynx,  the  patient  at  once  coughs  in  a  peculiar  man- 
ner, breathes  easier,  cyanosis  and  other  signs  of  dyspnea  disappear.  If 
the  tube  is  not  in  the  larynx,  instead  of  improvement  in  the  condition 
the  breathing  is  apt  to  be  worse;  the  cough  will  still  be  high  pitched, 
and  the  patient  may  even  collapse.  If  by  chance  the  tube  is  in  the 
esophagus,  the  string  will  shorten  as  the  tube  goes  down.  There  should, 
however,  be  no  question  as  to  the  location  of  the  tube/since  the  examina- 
tion by  the  forefinger  should  have  given  information  as  to  whether  or 
not  the  tube  is  properly  in  place.  The  child  should  be  watched  care- 
fully for  a  few  minutes,  and  if  the  breathing  is  comfortable  and  easy, 
should  again  be  placed  in  a  recumbent  position,  the  gag  reinserted, 
the  forefinger  of  the  left  hand  placed  upon  the  head  of  the  tube  in  the 
larynx,  the  silk  thread  held  with  the  right  hand,  cut  by  an  assistant,  and 
removed. 

It  is  not  uncommon  to  have  the  breathing  immediately  cease  ^yhen 
the  tube  is  inserted.  This  may  be  because  the  tube  is  not  in  the  larynx, 
but  this  question  among  experienced  operators  rarely  comes  up.  It 
is  usually- caused  by  the  aspiration  of  a  piece  of  membrane  into  the  tube, 
which,  of  course,  should  be  at  once  removed  and  cleaned.  Often,  after 
the  tube  is  removed,  the  patient  may,  after  a  series  of  spasmodic  coughs, 
eject  large  pieces  of  membrane.     The  breathing  may  in  this  way  be  so 


SS8  OPERATIONS    ON    THE    NECK 

much  relieved  that  it  will  be  unnecessary  to  reinsert  the  tube.  On  the 
other  hand,  reinsertion  may  be  very  urgent,  and  it  is  well  always  to  have 
two  or  three  tubes  of  each  size  at  hand,  that  in  such  an  emergency  there 
shall  be  no  delay  such  as  might  be  caused  by  cleaning  a  tube. 

Again,  it  may  happen  that  the  tube  is  pushed  into  a  mass  of  mem- 
brane and  secretion  and  does  not  pierce  it.  This  is  a  grave  condition 
and  respiration  stops.  If  the  tube'  is  removed,  the  chances  are  that 
considerable  loosened  membrane  will  be  coughed  up,  and  upon  rein- 
sertion of  the  tube  breathing  may  be  much  easier.  In  such  a  case  the 
tube  is  apt  to  plug,  and  repeated  intubation  and  extubation  may  be 
necessary. 

Further,  the  tube  may  loosen  a  flap  of  membrane  from  the  wall  of 
the  larynx,  which  will  act  as  a  valve  against  the  end  of  the  tube,  allowing 
inspiration,  but  preventing  expiration.  Suspecting  this,  a  short  tube 
of  the  French  type  may  be  tried. 

In  certain  uncommon  cases  the  tube  may  fail  to  relieve,  because  the 
membrane  not  only  covers  the  trachea,  but  reaches  into  the  finer  branches 
of  the  bronchi,  or  there  may  be,  in  addition  to  moderate  amount  of  mem- 
brane, a  capillary  bronchitis.  In  either  case  intubation  will  fail,  trache- 
otomy win  be  performed,  and  no  improvement  from  either  will  result. 
Such  cases  rarely  get  well  and  require  maximum  doses  of  antitoxin 
from  the  start. 

Occasionally  where  the  passages  of  the  nose  are  occluded  by  mem- 
brane and  edema,  and  likewise  by  swelling  of  the  tonsils  and  the  ad- 
jacent tissues,  the  anterior  atrium  of  the  pharynx  is  practically  occluded, 
and  dyspnea  arises  resembling  closely  that  produced  by  laryngeal  ob- 
struction. Intubation  in  this  case  will  obviously  not  relieve,  and  trache- 
otomy may  ha^^e  to  be  resorted  to  unless,  after  swabbing  the  throat  as 
free  as  possible  from  secretion,  mouth-breathing  is  restored. 

After-care. — The  after-care  of  intubation  cases  is  extremely  im- 
portant. Such  cases  should  be  grouped  together  so  that  they  can  be 
constantly  watched,  for  it  is  not  uncommon  for  a  child  to  cough  up  its 
tube  at  almost  any  time  and  for  immediate  reintubation  to  be  necessary. 
If  the  tube  is  coughed  and  swallowed,  such  a  complication  is  of  no 
serious  consequence.  In  case  there  is  much  loose  membrane  and  the 
tube  is  repeatedly  obstructed,  it  m.ay  be  well  to  leave  the  silk  thread,  so 
that  the  nurse  may  extract  the  tube  in  case  it  is  suddenly  blocked  and 
the  child  lacks  expulsi\"e  cough  of  sufficient  force  to  expel  the  tube.  If 
the  child  repeatedly  expels  the  tube,  a  larger  size  may  be  used,  or  to 
avoid  a  series  of  emergencies,  tracheotomy  may  be  necessary. 

Gradual  occlusion  of  the  tube  may  occur  from  the  accumulation  and 


intubation:  after-treatment  389 

drying  of  secretion  in  its  interior.  This  may  be  suspected  if  the  respira- 
tory murmur  gradually  becomes  higher  pitched  and  the  abdominal 
muscles  harden  at  each  expiration,  even  though  the  color  remains  good. 
The  nurse  should  be  taught  to  recognize  this  condition,  so  that  the  tube 
may  be  removed  and  cleaned  before  serious  dyspnea  results. 

Feeding. — Feeding  (see  also  Chapter  XIII,  p.  129)  in  intubation 
cases  is  rarely  a  serious  problem  unless  the  tube  is  retained  consider- 
ably longer  than  in  the  average  case.  Ordinarily,  bread  and  milk,  cus- 
tard, soft-boiled  eggs,  etc.,  are  swallowed  with  very  little  discomfort. 
The  patient  often  coughs  excessively.  Semisolid  foods  are  apt  to  pro- 
duce less  cough  than  hquids.  The  most  serious  comphcation  not 
directly  connected  with  intubation  is  bronchopneumonia.  The  treat- 
ment should  be  carried  out,  eliminating  drugs  so  far  as  possible.  The 
most  fa^•orable  thing  that  can  happen  is  that  the  patient  cough  up  the 
tube  and  no  longer  require  it. 

At  the  end  of  four  days,  however,  if  this  does  not  occur,  the  tube 
should  be  removed,  although  it  may  be  necessary  immediately  to  re- 
introduce it.  The  arrangements  of  the  patient  are  the  same  as 
for  intubation.  The  extractor  is  grasped  lightly  and  the  beak  follows 
forefinger  to  the  head  of  the  tube.  As  it  touches  the  metal  the  impact 
will  be  felt,  and  the  beak  is  moved  about  cautiously  until  it  drops  into 
the  opening  of  the  tube.  The  lever  of  the  extractor  is  then  pressed,  thus 
firmly  engaging  the  beak  in  the  tube.  The  tube  is  elevated  from  the 
larynx,  the  forefinger  being  placed  beneath  the  head  or  flange  of  the 
tube  to  prevent  it  slipping  from  the  extractor  during  removal,  and  the 
whole  withdrawn,  carrying  the  tube  upward  and  forward  in  the  arc  of 
a  circle.  If  the  child  breathes  well  during  the  first  twelve  hours,  the 
tube  wnll  ordinarily  not  require  reinsertion. 

Retained  Tubes. — It  sometimes  happens  that  the  patient  re- 
peatedly develops  signs  oi  stenosis  whenever  the  tube  is  rem.o\'ed,  in- 
definitely repeated  reintubation  has  become  necessary,  and,  finally, 
it  is  found  that  the  tube  m^ust  be  worn  continuously  or  intermittently. 
Fortunately,  such  cases  are  rare,  perhaps  i  per  cent,  or  less  of  the  total 
of  intubated  cases.  The  immediate  cause  is,  in  the  vast  majority  of  cases, 
the  contraction  of  scar  tissue  at  some  point  where  it  obstructs  the  breath- 
ing. This  scar  tissue  is  in  the  site  of  an  ulceration,  produced  by  pres- 
sure of  the  tube,  or  by  the  diphtheritic  membrane,  or  at  the  point  of 
some  trauma,  due  to  faulty  technique.  The  latter  should  be  preventable. 
To  eliminate  pressure  necrosis  the  tube  should  be  removed  in  all  cases 
at  the  earliest  possible  moment,  even  though  it  has  to  be  reintroduced 
at  once.     The  mortality  in  the  retained  tube  cases  is  commonly  due  to 


390  OPERATIONS    ON   THE   NECK 

bronchopneumonia.  If  the  patient  lives,  intermittent  intubation  must 
be  practised  for  a  long  time,  Avith  the  hope  that  eventually  the  tendency 
of  the  scar  tissue  to  contract  will  be  overcome. 

ESOPHAGOTOMY 

If  the  wound  in  the  esophagus  is  at  all  clean  cut,  such  as  after  the 
removal  of  a  foreign  body,  the  wound  should  be  closed  with  chromic 
catgut  and  the  neck  wound  dramed  down  to  these  sutures,  best,  probably, 
with  rubber  dam  or  a  soft-rubber  tube,  held  in  place  by  a  stitch  holding 
it  to  the  skin.  Secretion  from  the  wound  is  likely  to  be  a  form  of  a  pro- 
fuse, thin,  yellow  discharge  with  a  yeasty  smell.  The  wound,  therefore, 
calls  for  frequent  dressings.  For  the  first  seven  days  it  is  probably 
best  to  feed  the  patient  by  nutrient  enemas,  giving  only  a  little  ice  by 
mouth.  If  the  enemas  are  not  held  and  nourishment  is  urgently  needed, 
the  patient  may  be  fed  by  stomach-tube. 

Complications  and  Sequelae. — Sepsis.  —  These  wounds  are 
always  infected  and  frequently  present  large  sloughs  and  vile  discharge. 
The  woimd  must  be  thoroughly  wiped  out,  every  hour  if  necessary,  and 
kept  dressed,  with  salt  and  citrate  solution  at  first,  later  with  weak 
chlorinated  soda  or  myrrh  wash. 

PARTIAL  THYROIDECTOMY 

Anesthesia. — Dr.  Halsted^  says:  "I  am  not  convinced  that  very 
light  general  anesthesia  with  ether,  skilfully  given  by  an  expert  anes- 
thetist for  only  fifteen  or  twenty  minutes,  is  less  safe,  even  in  the  gravest 
cases,  than  local  anesthesia  plus  the  prolonged  operative  period  and 
its  attendant  nerve  strain.  In  operations  for  exophthalmic  goiter  the 
general  anesthesia  should  be  administered  only  by  an  expert. 

"A  nurse  trained  in  the  pre-  and  postoperative  care  of  cases  of 
Graves'  disease  should  be  in  charge,  and  the  patient  should  have  a 
private,  quiet  r.oom.  We  have  knowledge  of  no  analogous  disease  and 
of  no  toxemia  comparable  to  that  which  follows  operation  upon  people 
afflicted  with  hyperthyroidism.  It  is,  therefore,  particularly  difficult 
for  the  uninitiated  to  realize  how  critical  is  the  condition  of  so  many  of 
these  patients  until,  as  a  demonstration,  a  death  has  been  experienced. 

**  Water. — As  so  impressively  pronounced  by  Dr.  Mayo  at  his 
clinic,  saturation  of  the  patient  with  water  must  be  accomplished  in 
one  way  or  another.     The  surgeon  must  not  accept  excuses  that  water 

MVilliam  S.  Halsted,  jNI.D.,  and  Herbert  M.  Evans,  S.  B.,  Ann.  Surg.,  Oct.,  1907, 
xlvi,  "The  Parathyroid  Glandules:  Their  Blood-supply  and  their  Preservation  in  Oper- 
ation upon  the  Thyroid  Gland." 


PARTIAL    THYROIDECTOMY 


391 


could  not  be  given  by  mouth  because  it  hurt  the  patient  to  swallow, 
and  not  by  the  intestine  because  the  guttatim  injections  were  expelled, 
unless  the  patient  is  uncontrollable;  in  such  event  proper  resort  to 
subcutaneous  infusion  must  be  had." 

C.  H.  Mayo^  says:  "After  the  operation  the  patient  is  given  i  quart 
of  saline  slowly  per  rectum.  This  is  repeated  t\vice  ^^•ithin  the  next 
twelve  hours.  Should  intestinal  relaxation  be  present,  we  consider 
the  salines  of  sufficient  importance  to  give  them  subcutaneously  in  all 
severe  cases.  The  precordial  ice-bag  may  steady  a  rapid  heart;  atropin 
checks  excessive  perspiration,  and  morphin  quiets  restlessness.  Death 
from  operation  seldom  occurs  after  the  first  twenty-four  hours." 

As  to  chilling  or  freezing  the  neck  before  and  after  operations  for 
Graves'  disease,  Dr.  Halsted  remarks,  "It  had  not  occurred  to  me  at 


Fig.  115. — Thyrotoxicosis.  Fig.  116. — The  Same  Case  after  Operation. 

Bilateral  enlargement  and  exophthalmos,  before  Tumor  and  exophthalmos  gone.     Pulse  100  to  120. 

operation.     Pulse  170  to  216. 

first  that  excessive  cold  applied  to  the  neck  in  these  cases,  particularly 
after  operation,  might  delay  the  processes  of  repair  and  absorption  and 
thus  bridge  over  the  period  of  greatest  danger — the  t^^•o  or  three  days 
succeeding  operation.  Its  employment  was  very  imperfectly  tested  in 
three  instances,  but  in  all  with  beneficial  results,  it  seemed  to  me, 
although  one  of  the  patients,  desperately  ill  before  the  operation,  did 
not  recover.  In  no  instance,  unfortunately,  did  we  succeed,  with  the 
inadequate  appliances  at  our  disposal,  in  doing  much  more  than  slightly 
cool  the  surface  of  the  skin.  In  one  case,  thirty-six  hours  after  opera- 
tion, the  pulse,  which  had  been  steadily  rising  until  it  reached  iSo, 
dropped  30  beats  a  minute  Vvithin  one  and  one-half  hours  of  the 
application  of  the  cold.     In  another,  a  good  night's  sleep,  the  first  in 

^  Surg.  Gyn.  and  Obst.,  1909,  602. 


392 


OPERATIONS    ON    THE    NECK 


Mrfl  ft  \U  •\T\- 


weeks,  seemed  to  be  attributable  to  the  application  of  cold  to  the  neck.. 
It  is  quite  possible  that  harm  rather  than  good  might  be  done  by  inef- 
fectually apphed  ice-bags.  They  might  serve  as  a  poultice  if,  for  example, 
swathed  in  protecting  flannel,  or  if  negligently  attended  to.  The  danger 
of  reaction,  too,  must  be  constantly  borne  in  mind — the  reaction  follow- 
ing either  a  brief  or  a  prolonged  use  of  the  cold.  Therefore,  no  time 
should  be  lost  in  changing  the  packs,  and  ultimately  the  cold  should 
gradually  be  withdrawn.     I  doubt  the  ability  of  the  rubber  ice-bag  to 

produce  a  degree  of  cold  sufficient 
for  the  very  ill  cases,  or  the  non- 
conducting rubber  should,  perhaps, 
be  so  thin  that  rents  would  hardly 
be  avoidable.  In  some  cases  a  de- 
cree of  cold  low  enough  almost  to 
freeze  the  skin  miight  be  necessary. 
Possibly  to  be  considered  as  a 
method  of  treatment  for  desper- 
ately ill  cases  is  an  unclosed  wound 
constantly  irrigated  with  water  of 
the  desired  temiperature. 

"I  am  convinced  that  the  tox- 
emia is  not  simply  due  to  the  ab- 
sorption of  the  thyroid  secretion. 
Otherwise,  might  not  the  gravest 
cases  of  exophthalmic  goiter  be  safely 
treated  by  total  excision  of  the  thy- 
roid gland  ?  It  is  my  belief  that  the 
toxemia  incident  to  wound  healing  is 
badly  borne  by  the  subjects  of  hyper- 
thyroidism. On  several  occasions, 
soon  after  thyroid  lobectomy,  I  have 
seen  prompt  and  great  improve- 
ment follow  the  liberation  of  a 
dram  or  even  a  few  drops  of  reddish 
serum  from  the  wound.  Moreover,  the  typical  postoperative  toxemia 
may,  it  seems,  follow  operations  of  other  kinds  upon  patients  afflicted 
with  Graves'  disease.  Absorption  takes  place  continuously  during  the 
process  of  repair,  even  in  wounds  which  are  '  dry'  and  healing  throughout 
by  first  intention.  Thus  it  seems  to  me  quite  reasonable  to  hope  that 
something,  perhaps  much,  may  be  accomplished  by  the  adequate  em- 
ployment of  cold.     The  entire  neck,  fore  and  back  and  sides,  and  from 


YV, III, 

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Fig.  117. — Thyrotoxicosis. 

Right  (the  larger)  lobe  and  isthmus  of  thyroid 
tumor  removed.  Pulse  216  at  end  of  operation. 
Rogers-Beebe  serum  and  also  bromid  of  quinin 
used  during  convalescence.  (See  also  Figs.  1 15, 116.) 


PARTIAL    THYROIDECTOMY  393 

chin  to  chest,  might  be  made  so  cold  in  the  serious  cases  as  to  arrest 
for  a  time,  more  or  less  completely,  the  process  of  absorption  and  pos- 
sibly of  healing. 

"Furthermore,  if  absorption  from  the  wound  is,  even  in  a  measure, 
responsible  for  the  toxemia  so  badly  borne,  the  area  of  the  wound  sur- 
faces must  be  a  factor  influencing  the  result,  and,  if  so,  there  would  be 
in  this  an  indication  for  as  small  a  wound  as  feasible  in  certain  cases. 
A  vertical  skin  incision  to  avoid  reflection  of  a  flap  might  be  tested,  and 
less  complete  division  of  the  muscles  at  their  attachment  to  the  hyoid 
bone  might  sufiice  for  the  liberation,  in  the  manner  described  in  this 
paper,  of  the  superior  pole.  The  operation  of  ultraligation  might  thus 
be  effected  through  a  hole  just  large  enough  to  permit  the  delivery  of 
the  lateral  lobe  of  the  thyroid  gland." 

Complications  and  Sequelae. — (i)  Hemorrhage. — Bleeding  may 
be  so  general,  so  difficult  to  localize,  and  so  difficult  to  control  by 
hemostatic  forceps  that  one  may  be  forced  at  the  operation,  or  at  any 
time  during  the  first  forty-eight  hours  after  operation,  to  pack  the  capsule 
with  gauze  and,  possibly,  even  to  sew,  temporarily,  the  capsule  over 
the  packing.  To  wet  the  packing  with  adrenahn  (i :  looo)  makes  it 
more  efficient. 

(2)  Much  handling  of  the  gland  during  its  removal  may,  apparently, 
squeeze  into  the  wound  an  amount  of  thyroid  secretion  sufficient  to. 
cause  symptoms  of  thyroidism}     For  this  reason,  rubber-dam  drainage 

^  "  '  I  take  it  that  squeezing  the  gland  may  help  to  liberate  secretion  contained  in  the 
follicles,  and  that  the  same  may  escape  into  the  wound  from  the  lymphatics  in  the  di\'ided 
capsule  around  the  severed  isthmus,  the  lymphatics  being  the  normal  channel  for  absorp- 
tion of  the  secretion.  If  the  condition  from  which  these  patients  suffered  is  to  be  regarded 
as  thyroidism,  and  not,  as  Mr.  Horsley  has  said,  athyroidisrn,  then  every  possible  source 
of  contamination  of  the  wound  with  thyroid  secretion  should  be  avoided.  I  cannot  rec- 
ommend that  the  safe  grasp  of  the  gland  should  be  altogether  given  up;  but  I  believe  that 
it  may  be  rendered  harmless  by  first  ligating  the  isthmus,  and  exercising  caution  in  the 
operation,  iiandle  the  gland  carefully,  and  at  once,  on  the  barest  suggestion  of  the  train  of 
symptoms  referred  to,  open  up  the  wound,  irrigate  it,  and  fill  with  dry,  aseptic,  absorbent 
wool.'  In  the  first  of  the  two  cases  related  by  Mr.  Paul  in  the  paper  mentioned  above, 
which  ended  fatally  just  two  and  a  half  days  after  the  operation,  the  wound  at  the  necropsy 
contained  fluid  of  a  very  watery  character.  Belie\'ing  that  the  grave  symptoms  were  due 
to  absorption  of  thyroid  secretion,  Mr.  Paul,  when  his  second  case  began  to  show  symptoms 
which  were  a  repetition  of  the  first,  about  twenty-four  hours  after  the  operation,  opened 
the  wound  and  filled  it  vdth  a  dry  salicylic  wool.  This  was  followed  by  a  marked  improve- 
ment, but  only  for  a  time.  Duriiig  the  second  night  after  the  operation  the  patient  'be- 
came worse  than  ever;  the  temperature  was  104.8°  F.,  the  pulse  almost  uncountable,  the 
respirations  36.  I  removed  the  plug  of  wool,  and  found  it  saturated  with  watery  dis- 
charge, replaced  it  with  dry  wool,  and  left  instructions  that  it  was  to  be  changed  as  often 
as  it  became  moist,  which  proved  to  be  about  every  two  hours.  The  following  day  she 
was  better  in  every  way.     The  day  after  the  temperature  was  only  just  above  normal, 


394  OPERATIONS    ON    THE    NECK 

should  always  be  used  at  the  lower  end  of  the  vertical  part  of  the 
wound. 

(3)  Injury  to  the  Recurrent  Laryngeal  Nerve,  Asphyxia,  Aphonia. — • 
The  inferior  laryngeal  nerve  may  be  wounded  in  the  operation,  or 
injured  by  pulling  or  contusion  during  operation,  or  may  be  later  com- 
pressed by  the  scar.  It  may  already  have  been  injured  before  opera- 
tion. The  cricothyroid  branch  of  the  superior  laryngeal  may  suffer 
any  of  these  injuries.  Dyspnea  and  aphonia  arising  from  any  of  these 
causes  need  not  always  be  permanent.^  Any  of  these  nerve  injuries 
are  liable  to  occur  where  the  tumor  is  large,  is  very  closely  adherent, 
very  broad  in  its  base,  when  it  extends  around  the  trachea  and  esopha- 
gus, or  when  it  is  malignant. 

(4)  Sepsis.- — Infection  of  the  thyroidectomy  wound  is  likely  to  de- 

and  continued  so  until  convalescence  was  established,  but  the  pulse  and  respirations  wore 
down  more  gradually.' 

' '  While  I  never  squeeze  the  gland,  but  limit  the  handhng  of  it  to  shelling  it  out  from 
adjacent  important  structures,  and  while  I  have  never  seen  the  watery  secretion  described 
by  Mr.  Paul,  the  course  of  the  case  has,  on  three  or  four  occasions,  so  closely  resembled 
that  described  by  Mr.  Paul,  that  I  cannot  doubt  the  explanation  which  he  gives  of  this 
insidious  and  sometimes  fatal  complication  is  the  correct  one"  (Jacobson  and  Steward,  i, 

532)- 

^  "In  a  woman,  aged  twenty-five,  suffering  from  suffocating  dyspnea,  the  operation 
was  followed  by  aphonia,  which  lasted  for  three  months,  and  by  complete  paralysis  of  the 
cords.  The  operation  was  performed  with  great  care,  and  there  is  no  reason  to  think  that 
either  of  the  recurrents  was  cut,  but  it  is  possible  that  they  were  bruised  or  stretched; 
however,  in  four  months  the  cords  regained  movement  and  the  voice  was  fully  restored. 

"  In  the  second  case,  aged  twenty,  a  hard,  m.obile  tumor,  the  size  of  a  walnut,  was  at- 
tached to  the  isthmus  by  a  narrow  pedicle,  and  the  gland  itself,  though  apparently  some- 
what hypertrophied,  was  not  prominent,  but,  when  exposed,  it  was  found  that  the  tumor 
had  a  broad  attachment  to  the  isthmus,  and  that  the  two  lobes  of  the  thyroid  were  greatly 
hypertrophied,  closely  embracing  and  compressing  the  trachea;  it  was,  therefore,  thought 
desirable  not  only  to  remove  the  tumor,  but  also  to  dissect  out  the  whole  gland.  When 
recovering  from  the  effects  of  chloroform,  the  patient  was  suddenly  seized  with  cyanosis 
and  threatening  asphyxia,  and  though  she  partially  recovered,  on  the  next  day  there  were 
aphonia,  dysphagia,  and  uninterrupted  dyspnea,  and  she  died  asphyxiated  in  the  evening. 
Both  recurrent  laryngeals  had  been  cut,  and  the  upper  end  of  the  left  one  was  included  in  a 
ligature. 

"  In  June,  1894,  this  being  my  fifteenth  case  of  removal  of  the  isthmus  and  one-half 
of  the  thyroid,  I  met  with  this  complication,  which  was,  however,  not  permanent. 

"  The  patient  was  aged  thirty-five,  the  subject  of  an  ordinary  soUd  bronchocele,  of  large 
dimensions,  the  right  lobe  being  7  inches  long.  The  voice  was  decidedly  weak  before  the 
operation,  but  while  this  presented  no  difficulties  and  was  not  accompanied  by  any  cyano- 
sis, dyspnea,  etc.,  it  was  followed  by  marked  aphonia,  the  voice  being  almost  reduced  to 
a  loud  whisper.  The  right  vocal  cord  was  now  found  to  be  motionless.  Complete  re- 
covery had  taken  place  when  the  patient  was  last  seen  in  April,  1895.  I  have  recently 
(February,  1899)  seen  the  patient  again,  on  account  of  a  Colles  fracture.  Her  voice  is 
good,  though  a  little  weak.  Since  1895  she  has  been  following  her  occupation  as  a  cook." 
(Jacobson  and  Steward,  i,  533,  534.) 


SERUM    FOR    THYROTOXICOSIS  395 

velop,  particularly  where  the  tumor  dips  down  behind  the  sternum; 
because  of  the  difficulty  of  adequately  draining  this  region.  Careful 
and  frequent  dressings  are,  therefore,  indicated. 

(5)  Myxedema  (A  thyroid  ism,  Cachexia  Strumipriva) . — This  condi- 
tion, following  thyroidectomy,  has  now  received  adequate  explanation 
through  the  researches  of  Dr.  Halsted,  and  the  first  treatment  of  it  is 
necessarily  preventive,  namely,  to  avoid  removal,  with  the  tumor,  of  the 
parathyroid  glandules. 

The  Reaction  Following  the  Injection  of  Serum.* — The 
serum  is  made  by  inoculating  rabbits  or  sheep  with  the  pure  proteids 
from  the  human  thyroid  gland. 

The  serum  is  always  given  by  hypodermic  injection,  and  we  have  chosen 
the  arm  as  the  site  of  injection  because  it  is  more  convenient  for  the  patient 
and  because  the  local  reaction  causes  less  trouble  in  this  region  and  may 
be  treated  more  readily.  The  upper  arm  just  below  the  deltoid  should  be 
carefully  cleaned  and  the  injection  made  subcutaneously,  but  not  intramuscu- 
larly, in  order  to  avoid  too  rapid  absorption.  In  95  per  cent,  of  the  injections 
the  local  reaction  consists  only  of  an  area  of  hyperemia  and  slight  indura- 
tion which  may  be  somewhat  tender  on  pressure  for  a  few  hours.  It  quickly 
clears  up,  and  in  thirty-six  to  forty-eight  hours  the  arm  is  perfectly  nor- 
mal. The  indurated  area  may  in  some  instances  be  three  or  four  inches  in 
diameter,  and  occasionally  the  whole  arm  has  become  edematous  from  the 
shoulder  to  the  finger-tips.  Such  a  reaction  is  unpleasant,  but  fortunately 
it  is  a  rare  complication,  and  if  the  arm  is  wrapped  in  a  wet  dressing,  the  re- 
action subsides  without  unpleasant  after-effects.  The  exact  nature  of  the 
reaction  in  any  given  case  cannot  be  foretold  because  the  matter  of  personal 
idiosyncrasy  of  the  patient  is  an  exceedingly  important  factor.  It  is  best, 
therefore,  to  start  with  a  small  dose  and  to  determine  the  nature  of  the  re- 
action in  each  case  before  the  full  therapeutic  dose  is  attempted.  As  has 
already  been  stated,  the  very  acute  toxic  cases  take  the  serum  better  than 
the  mild  cases,  and  with  them  it  may  be  best  to  keep  hot  applications  on  the 
arm  for  half  to  three-quarters  of  an  hour  after  the  injection,  and  gently  mas- 
sage the  area  about  the  point  of  puncture.  Unless  some  quite  unusual  con- 
dition results,  no  further  treatment  is  necessary,  for  the  condition  subsides 
promptly.  If  a  second  injection  is  made  before  the  reaction  from  the  first 
has  subsided,  a  more  decided  reaction  is  produced  in  the  second  instance 
and  the  area  of  the  first  injection  is  again  excited.  The  local  reaction  is, 
therefore,  of  value  as  a  guide  in  the  determination  of  dose  and  frequency  of 
administration.  The  two  arms  should  be  used  alternately  as  the  site  of 
injection. 

The  general  reaction  likewise  shows  consideral^le  variation.     In  a  large 

^  John  Rogers  and  S.  P.  Beebe,  The  Treatment  of  Thyroidism  by  a  Specific  Cyto- 
toxic Serum,  Mutter  Lecture,  College  of   Physicians,  Philadelphia,  Dec.   13,  1907. 


396  OPERATIONS    ON    THE    NECK 

percentage  of  cases  there  is  no  disturbance  whatever;  there  may  be,  how- 
ever, a  sHght  rise  in  temperature,  accompanied  by  nausea,  some  restless- 
ness, and  perhaps  some  increase  in  the  tachycardia.  Rarely  the  patient  may 
vomit  and  all  the  symptoms  of  the  disease  be  temporarily  exaggerated.  If 
the  serum  is  given  too  frequently  or  in  too  large  doses,  both  the  local  and  the 
general  reactions  become  more  severe.  The  serum  must  'never*  be  pushed 
in  the  presence  of  a  progressively  increasing  reaction.  Serious  consequences 
may  arise  if  this  precaution  is  not  observed.  If,  during  the  course  of  treat- 
ment, an  unusually  severe  reaction  has  been  obtained,  it  is  best  to  allow  a 
somewhat  longer  interval  before  the  next  injection,  and  at  the  same  time  to 
reduce  the  dose. 

The  relation  which  the  specific  treatment  bears  to  the  surgical  treatment 
is  naturally  of  much  interest.  The  list  of  141  patients  includes  8  who  have 
had  some  surgical  procedure  for  the  condition.  To  summarize  these  cases,  5 
patients  tried  serum  first  without  benefit  and  later  died  as  a  result  of  opera- 
tion; two  were  operated  on  before  the  serum  treatment  with  good  result  and 
were  later  treated  successfully  with  serum  for  a  recurrence  of  the  disease,  and 
the  last  was  benefited  considerably  by  serum  treatment  preliminary  to  a  com- 
pletely successful  operation.  As  far  as  these  figures  go  it  would  seem  that 
if  a  case  cannot  be  benefited  by  serum,  it  may  be  dangerous  to  operate;  and 
also  that,  if  an  operation  is  likely  to  be  successful,  serum  may  also  be  success- 
ful. It  appears  to  be  true  that  the  type  of  case  which  can  be  completely 
cured  by  operation  is  a  type  favorable  for  serum  treatment. 

Conclusions.- — This  work  is  the  first  attempt  to  treat  disease  in  the  human 
subject  by  means  of  a  specific  cytotoxic  serum,  and  our  conclusions,  subject 
to  revision  as  experience  increases,  are  as  follows: 

T.  The  serum  has  a  specific  effect  in  neutralizing  the  toxic  action  of  the 
thyroid  secretion. 

2.  As  a  therapeutic  agent  it  gives  results  which  cannot,  in  many  cases,  be 
attained  by  any  other  medical  means. 

3.  Not  all  cases  presenting  symptoms  of  thyroidism  can  be  treated  success- 
fully with  serum,  because  not  all  cases  are  purely  hypertrophic  in  origin. 

4.  The  rapid  amelioration  of  symptoms  in  the  acute  toxic  cases,  similar 
in  most  respects  to  the  well-accepted  instances  of  neutralization  of  toxin  by 
antitoxin,  is  a  weighty  argument  in  favor  of  believing  the  symptoms  to  be  due 
to  the  toxic  effects  of  h}'perthyroidism. 

5.  The  beneficial  results  of  combined  treatment,  especially  in  the  older 
cases,  indicates  a  dysthyroidism  as  well  as  hyperthyroidism  as  a  factor  in  the 
production  of  symptoms. 

EXCISION  OF  LYMPH-NODES  OF  THE  NECK 

After  extensive  dissections,  the  first  dressing  may  be  covered  with  a 
layer  or  two  of  plaster-of-Paris  bandage  for  immobilization. 

These  cases  may  be  properly  drained  with  rubber  dam  or  spiral 


CARBUNCLE    OF    THE    NECK  397 

drain,  but  if  the  cavity  is  clean  and  dry  at  the  end  of  operation,  it  may 
be  merely  packed  with  iodoform  or  formidin  gauze.  This  packing  or 
drain  is  usually  left  in  place  three  to  five  days.  At  the  end  of  that  time 
the  drain  is  removed,  the  cavity  swabbed  out  with  full-strength  tincture 
of  iodin,  the  skin  about  the  wound  being  protected  with  ointment,  and 
the  cavity  may  be  packed  again,  but,  better  still,  exposed  without  any 
covering  to  direct  sunlight  for  as  many  hours  as  possible  each  day. 

The  cannula  designed  by  Briggs  is  often  valuable  in  the  case  of 
isolated  abscesses  in  regions  where  cosmetic  results  cannot  be  disre- 
garded. It  consists  of  two  surfaces  of  silver,  curved  laterally,  bent 
outward,  and  joined  at  the  angle.  The  cut  through  the  skin  being 
made  (^  inch),  the  knife  is  pushed  into  the  abscess.  Upon  its  with- 
drawal the  cannula  is  inserted  as  in  Fig.  ii8.  When  the  joint  is  reached, 
the  external  arms  are  closed.  This  reverses  it.  The  internal  arms 
open,  dilating  the  tissues  in  the  vicinity  of  the  cut  and  retaining  the 
cannula  within  the  cavity,  while  the  external  arms  come  together  and 
make  a  tube  (Fig.  119).  A  projection  at  the  end  of  each  external  arm 
prevents  it  from  falling  into  the  abscess-cavity,  and  it  is  fixed  in  situ. 


Fig.  118.  Fig.  iiQ.  ■ 

Figs.  ii8,  119. — Briggs'  Self-retaining  Drainage  Cannula  (Enlarged). 

It  is  removed  by  seizing  one  of  the  external  arms  and  withdrawing 
it  until  the  hinge  is  reached,  when,  by  spreading,  it  is  again  as  in 
Fig.  118,  and  easily  slides  out.  This  cannula  can  be  cleaned  and  ster- 
ilized, and  gives  free,  continuous,  and,  if  necessary,  permanent  drain- 
age through  a  skin-cut  of  barely  |-  inch.  It  reduces  the  cut  to  an 
undoubted  minimum,  gives  surgical  drainage,  and  leaves  the  least 
possible  resultant  scar.^ 

INCISION  AND  EXCISION  OF  CARBUNCLE  OF  THE  NECK 

If  a  crucial  incision  only  is  made,  the  wound  then  calls  for  the  general 
treatment  of  a  septic  wound. 

^  F.  M.  Briggs,  Boston  Med.  and  Surg.  Jour.,  1895,  cxxxii,  433. 


398 


OPERATIONS    ON    THE    NECK 


If  the  more  modern  method  of  complete  excision  of  the  carbuncle  is 
employed,  the  problem  becomes  within  twenty-four  hours  merely  that 
of  a  large  granulating  wound.     Such  a  wound  should  be  cleaned  twice 

a  day  at  least,  this  being  one  of  the 
places  where  hydrogen  dioxid  works 
well.  Small  suppurating  points  or  bits 
of  slough  in  the  margin  of  the  wound 
must  be  carefully  removed  and  the 
region  disinfected.  The  dressing  con- 
sists of  a  pad,  wet  for  the  first  three  or 
four  days  with  salt  and  citrate,  and  later 
with  glycerin  or  balsam  of  Peru  laid 
within  the  wound.  The  dressing  is  held 
on  by  means  of  a  bandage,  the  upper 
margin  of  which  is  held  up  and  pre- 
vented from  gaping  from  the  neck  by 
pinning  it  to  a  tape  skull-cap,  as  in 
Fig.  1 20. 

General  treatment  counts  for  much 
in  these  cases.  The  patient  should  be  out-of-doors  from  the  first,  if 
it  is  feasible.  General  stimulation  should  be  free  and  close  attention 
paid  to  elimination.  To  prevent  recurrence  serum  treatment  may  be 
resorted  to.     (See  Chapter  LII.) 


Fig.  120. — Carbuncle  of  the  Neck. 

Tape  skull-cap  to  which  dressing  is  held 
by  pins.  This  avoids  bandage  over  the  head 
and  also  avoids  gaping  of  dressing  from  the 
neck. 


BRANCHIAL  CYSTS  AND  SINUS 

These  epiblastic  remains  may  appear  in  positions  corresponding  to 
any  one  of  the  four  gill-clefts,  from  the  level  of  the  ears  to  the  root 
of  the  neck.  Eradication  usually  calls  for  extensive  dissection.  Even 
after  such  dissection,  however,  at  the  end  it  may  be  found  necessary  to 
leave  a  portion  of  the  epithelial  lining,  to  be  destroyed  later  by  successive 
cauterizations.  In  any  case,  it  is  attempted  to  heal  these  wounds  by 
granulation.  They  are,  therefore,  packed  at  first  and  are  treated  as 
aseptic  granulating  wounds.     They  may  take  months  to  heal.^ 


MASTOIDITIS 

Ordinarily,  shock  is  slight  after  a  mastoid  operation  and  pain  is 
usually  not  severe  enough  to  demand  an  anodyne.  If  it  does  occur 
during  the  first  twenty-four  hours,  the  external  dressing  should  be  care- 
fully examined  to  see  if  the  pinna  has  been  twisted,   and  reapplied. 

^  M.  Chevasser,  Les  Systes  Branchiaux  &  Structures  Phar\ngo-saUvaire  et  en  Parliculier 
les  Systes  Presternaux,  Rev.  clc  Chir.,  Paris,  igo8,  xxxvii,  411. 


MASTOIDITIS  399 

After  twenty-four  hours,  if  pain  is  present,  the  skin-flaps  should  be 
examined  for  possible  infection  or  swelling  and  tension  of  the  sutures. 
Sutures  should  be  removed  if  too  tense.  The  patient  may  complain 
of  a  soreness  or  stiffness  of  the  muscles  of  the  neck  on  the  operated  side, 
due  to  partial  or  complete  separation  of  muscular  attachments  from 
the  mastoid  tip.  This  condition  quickly  subsides,  but  it  may  be  neces- 
sary to  strap  adhesive  plaster  over  the  neck  to  assist  in  keeping  the 
muscles  at  rest. 

The  length  of  time  that  the  first  dressing  should  be  left  undisturbed 
depends  on  several  conditions.  If  the  temperature  remains  normal 
or  but  slightly  elevated,  pain  absent,  and  the  dressings  dry,  sweet,  and 
clean,  the  wound  should  not  be  disturbed  for  five  or  six  days  after  the 
operation.  Saturation  of  the  dressing  with  exudate  or  blood,  causing 
foul  odor  or  great  stiffness,  is  a  cause  for  early  change  of  dressing. 


Fig.  121. — Bandage  I-roperly  Applied  to  Hold  Dressing  in  Place  .After  Mastoid  Oper.ation. 

Extreme  gentleness  should  be  exercised  when  removing  the  gauze  from 
the  wound.  If  the  dressing  has  to  be  removed  before  the  sixth  day,  it 
is  apt  to  be  adherent  and  cause  pain  if  force  is  used  in  removal.  Wetting 
the  gauze  will  so  dislodge  the  adherent  threads  that  their  remo\al  causes 
no  pain.'  After  the  fifth  or  sixth  day  the  dressing  is  usually  wet  from 
the  excretions  and  may  be  removed  without  pain.  Irrigation  of  the 
wound  at  the  first  dressing  is  seldom  necessary.  All  dry  blood  or  excre- 
tion should  be  softened  and  removed  by  wet  pledgets  of  cotton.  Boric 
acid  should  be  insufflated  into  the  wound  cavity,  sterile  strips  of  gauze 
applied  loosely,  and  a  roller  bandage  applied  over  the  fresh  dressing. 
The  subsequent  dressings  may  be  made  every  t\venty-four  to  forty-eight 
hours,  depending  on  the  amount  of  discharge. 

The   open   mastoid   wound   heals   by  granulation,   and   the   gauze 
.dressing  should  be  used  to  prevent  the  wound  closing  too  soon,  as  a 


400 


OPERATIONS    ON    THE    NECK 


sinus  may  result,  leading  to  a  diseased  cavity.  The  granulations  should 
be  small  and  firm.  If  otherwise,  they  should  be  curetted  or  stimulated 
with  balsam  of  Peru  or,  if  necessary,  with  the  nitrate  of  silver  pencil. 
If  unhealthy  granulations  develop  on  the  edges  of  the  incision  in  the 
skin,  and  partly  close  the  entrance  into  the  cavity,  they  should  be  curetted 
until  entirely  removed.     If  eczema  develops  about  the  skin  during 

con\'alescence,  it  may  be  due  to  the 
use  of  iodoform  gauze,  and  soon  dis- 
appears after  plain  sterile  gauze  is  sub- 
stituted. 

To  avoid  formation  of  scales  and 
small  crusts  about  the  auditory  canal  or 
in  the  vicinity  of  the  mastoid  antrum, 
Wright's  citrated  saline  solution  may  be 
used  several  times  a  week. 

After  a  week,  and  in  some  cases  on  the 
fourth  or  fifth  day,  the  patient  may  sit  up 
in  a  chair  and  walk  about  the  room.  In 
radical  cases  the  patient  should  stay  in 
bed  for  one  week,  and  longer  if  the  dura 
or  lateral  sinus  has  been  exposed. 

Healing  may  be  complete  within  a 
month.  In  some  exceptional  cases  a 
shorter  period  is  sufficient,  or  a  much 
longer  period  may  be  required.^ 

Complications  and  Sequelae.— 
(i)  Thrombosis  of  Lateral  Sinus  and  In- 
ternal Jugular. — This  may  follow  acci- 
dental opening  of  sinus  during  operation 
(Fig.  122),  or  may  result  from  advance 
of  the  infection.  If  redness,  tenderness, 
or  induration  are  observed  along  the  de- 
scending line  of  the  internal  jugular,  immediate  operation  should  be 
done  to  tie  the  vein  proximal  to  the  clot. 

(2)  Cerebral  abscess  {epidural  or  subdural)  is  suggested  by  continuing 
fever  without  adequate  apparent  cause  in  the  wound,  intense  headache, 


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Fig.  122. — Mastoid  Abscess. 
Lateral  sinus  opened,  packed  with  iodo- 
form gauze.     No  apparent  infection  of  in- 
ternal jugular.    Immediate  drop  of  temper- 
ature when  sinus-packing  was  removed. 


nausea,  vertigo, 
reached. 


Extensive  operation  is  imperative  if  this  diagnosis  is 


^  Philip  Hammond,  Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  p,  1645. 


CHAPTER  XLIII 

OPERATIONS  ON  THE  THORAX 
AMPUTATION  OF  THE  BREAST 

Uncomplicated,  if  it  has  been  possible  entirely  to  cover  in  the  area 
with  skin-flaps,  the  after-care  of  this  operation  should  be  only  that  of 
a  simple  incised  wound.  The  best  dressing  after  the  complete  operation 
is  the  double  swathe — the  first  around  the  thorax,  high  in  the  operated 
axilla,  the  second  swathe  outside  the  affected  arm,  wide  enough  to  be 
folded  over  the  shoulders.  This  binds  the  arm  to  the  side,  gives  good 
pressure  on  the  dissected  axilla,  and  at  the  same  time  fixes  the  arm 


Fig.  123.— Application  of  Swathe    After  Fig.    124.— Application  of  Swathe  After 

Breast  Amputation.  Breast  Amputation. 

The  under  swathe  exerts    even  compression   and  The    outer   swathe    applied  bringing  arm    in 

holds  on  the  major  part  of  the  dressing.  against  the  chest,  holding  the  axillary  part  of  the 

dressing,  supporting  the  forearm  and  wrist. 

(Figs.  123, 124).  The  affected  hand  is  supported  by  a  narrow  sling  under 
the  second  swathe,  but  the  forearm  is  free  and  early  motion  of  it  is 
encouraged.  In  many  cases  there  is  so  much  oozing  that  it  seems  best  at 
the  end  of  operation  to  insert  a  rubber-dam  drain  through  the  posterior 
part  of  the  axillary  flap.  This  drain  should  be  removed  at  the  end  of 
twenty-four  to  forty-eight  hours.  These  patients  may  suffer  greatly 
from  thirst,  due  to  loss  of  blood.  They  should  sit  up  on  the  day  after 
26  ^01 


402 


OPERATIONS    ON    THE    THORAX 


operation,  unless  the  prostration  of  shock  or  hemorrhage  forbids.   Stitches 
out  on  the  tenth  day. 

Complications  and  Sequelae.  —  (i)  Skin-grafting.  —  Primary 
skin-grafting  at  the  time  of  operation  is  being  done  constantly  more  and 
more,  as  surgeons  observe  that  miost  local  recurrences  are  in  the  skin. 
For  treatment  of  the  wound  which  has  been  grafted,  see  p.  572. 

(2)  Embolism,  arising  in  the  axillary  or  subclavian  vein,  is  always 
a  fearful  possibility.     This  is  practically  always  fatal. 

(3)  Injury  to  the  thoracic  duct  has  been  repeatedly  observed.  (See 
p.  245.) 

(4)  Secondary  hemorrhage,  due  nearly  always  to  sepsis,  is  seen 
now  constantly  less  often.  If  outside  pressure  fails  to  arrest  it,  a  few 
stitches  are  removed  and  packing  is  tried.  This  failing,  however,  the 
flap  must  be  turned  back  with  all  precautions  and  an  effort  made  to 
catch  and  tie  the  bleeding  vessel. 

(5)  Recurrence  in  the  Scar. — The  advisability  of  immediate  treatment 
of  these  scars  by  exposure  to  the  .x-ray  should  be  considered.    (See  p.  347.) 

EXCISION  OF  BENIGN  TUMORS  OF  THE  BREAST 
These  cases  should  present  only  a  small  incised  wound,  made  pre- 
ferably at  the  periphery  of  the  breast,  where  the  scar  will  not  show. 


Fig.  125. — Breast-bandage. 
A  folded  towel  is  doubled  into  a  V  of  which  one 
arm  goes  above  the  breasts  and  one  below,  meeting 
in  the  opposite  axilla.  The  angles  are  pirmed  to  the 
respective  ends  of  a  folded  towel  behind  the  back. 
The  folds  are  connected  between  the  breasts; 
shoulder-straps  are  applied  (Boston  Lying-in  Hos- 
pital). 


Fig.  126. — Breast-bandage. 
To   exert  still  greater  pressure  an  extra  towel 
may  be  pinned  across  from  axilla  to  axill;i.    Ab- 
sorbent cotton   is   tucked    in   here    and    there   to 
equalize  the  pressure. 


Firm  pressure  should  be  maintained- for  four  or  five  days  to  prevent 
the  cavity  filling  with  blood  or  serum.     Stitches  are  taken  out  in  eight 


ABSCESS    OF   BREAST 


403 


to  ten  days.  If  it  has  been  possible  to  make  a  beveled  incision,  the 
wound  can  be  held  together  by  plaster  straps,  and  there  will  be  no 
stitches  to  remove  and  practically  no  scar  to  be  found. 


Fig.  127. — Breast-bandagk. 
Rear  view,  to  show  application  of  shoulder-straps. 


ABSCESS  OF  BREAST 

No  amount  of  good  after-treatment  will  make  up  for  an  inefficient 
operation  in  this  affection.  Drainage  wounds,  it  is  fair  to  say,  are  fre- 
quently insufficient  in  size,  and  are  not  made  at  the  places  best  adapted 
for  drainage.  The  cavity  should  never  be  curetted.  It  should  be 
distended  by  gauze  packing  (plain  or  chemically  treated)  at  the  time 
of  operation.  This  should  be  removed  at  the  end  of  one  or  two  days, 
depending  on  the  indication  given  by  temperature  or  pain.  The  pack- 
ing has  now  made  the  irregular  cavity  into  a  unit.  At  the  first  dressing 
the  cavity  may  be  filled  with  glycerin  or  balsam  of  Peru  and  a  small 
wick  or  soft-rubber  tube  inserted.  At  each  subsequent  dressing  the 
wound  is  wiped- out  with  gauze,  the  same  emollient  and  stimulating 
preparation  as  before  poured  in,  and  a  small  drain  used.  Salt  and 
citrate  dressings  with  judicious  use  of  Klapp's  suction  cups,*  with  or 
without  vaccine  therapy,  may  cause  rapid  subsidence  of  the  process. 
All  the  time  a  tight  swathe  arid  the  position  of  the  body  are  to  be  used 
to  favor  thorough  drainage.  Extensions  of  the  process  must  be  met  by 
further  incision.  A  thoroughly  infected  breast  may  be  drained  by  a 
circular  incision  one-quarter  to  one-third  of  the  circumference  of  the 
base  of  the  breast,  breaking  down  all  cavities  into  tin's  incision.     The 

^  R.  L.  de  Normandie,  Boston  Med.  and  Surg.  Jour.,  1909,  clx,  601. 


404 


OPERATIONS    ON    THE    THORAX 


same  after-treatment  is  used.  Large  suction  cups  may  be  obtained  for 
the  application  of  the  Klapp  treatment  of  passive  hyperemia  to  the 
breast  if  indications  arise. 

The  patient  should  sit  up  as  soon  as  possible,  and  every  means, 
physical  and  psychologic,  should  be  used  for  legitimate  stimulation. 
In  cases  of  small  abscess,  and  in  cases  where  the  patient,  within  a  day 
or  two,  gets  distinctly  better,  the  flow  of  milk  may  be  maintained  in  the 
other  breast  and  nursing  shortly  resumed. 

EMPYEMA 

A  soft-rubber  bobbin  or  spool,  a  tube  from  ^  to  i^  inches  long,  on  each 
end  of  which  is  a  lip  or  flange  (Fig.  128),  is  the  best  apparatus  for  main- 
taining free  pleural  drainage.  It  is  self-retaining,  reaches  through  the 
parietal  pleura,  and  no  further.     The  inner  end,  unlike  the   common 


Fig.  12S. — Empyema.     Forms  of  Drainage-tubes. 
A,  Double   fenestrated  soft-rubber  tube;  B',  B^,  B^,  soft-rubber   drainage   bobbins  and  flanged  tubes  of 

different  lengths. 

drainage-tube,  does  not  reach  and  injure  the  lung.  If  a  fenestrated 
drainage-tube  is  used,  a  safety-pin  at  right  angles  through  the  outer 
end  will  prevent  the  tube  from  slipping  into  the  pleural  cavity  (Fig. 
128). 

It  seems  best  not  to  wash  out  the  pleural  cavity,  though  some  surgeons 
do  it.  It  is  apparent  that  each  time  the  washing  fluid  is  passed  in  the 
same  hydraulic  conditions  as  in  the  original  empyema  are  reestab- 
lished for  the  moment,  and  then  drained  off.  This  alternation  must 
be  to  a  degree  shocking.  A  very  voluminous  dressing  of  sterile  pads 
should  be  applied  and  held  by  a  swathe.  These  pads  require  changing 
usually  within  the  first  hour,  and  perhaps  every  two  or  three  hours  in 
the  first  twenty-four.  After  that,  the  amount  of  drainage  may  become 
rapidly  less.     The  patient  should  be  placed  in  bed  with  the  drainage 


EMPYEMA 


405 


hole  down;  that  is,  he  is  placed  on  the  affected  side  with  a  slight  inclina- 
tion backward,  the  first  criterion  in  posture,  however,  being  the  position 
in  which  breathing  is  least  difl&cult.  The  tube  must  frequently  be 
probed  with  a  sterile  instrument  or  finger  to  see  that  it  has  not  become 
plugged  with  fibrin  or  blood-clot,  and  should  be  kept  in  position  in  any 
case  about  a  w^eek,  and  if  drainage  is  then  profuse,  still  longer. 

These  patients  should  be  carried  almost  immediately  out-of-doors  and 
best  sitting  up.  If  adequate  protection  and  nursing  can  be  provided,  they 
should  sleep  out-of-doors.  Lung  exercises,  such  as  deep  breathing  and 
blowing  fluid  from  one  bottle  to  another  (Fig.  129),  should  be  started 
as  early  as  the  end  of  the  first  week.  In  a  patient  who  is  at  all  intelligent, 
as  soon  as  he  has  the  strength  a  tube  may  be  sealed  (Fig.  130)  in  the 


Fig.  129. — Empyema. 
Arrangement  of  bottles  whereby  patient  increases  lung  capacity  and  lessens  open  cavity. 


wound  (say  at  the  end  of  two  weeks),  and  in  the  end  of  this  tube  the 
patient  himself,  from  .time  to  time,  perhaps  five  or  six  times  a  day, 
inserts  an  ordinary  suction-syringe  bulb  and  pumps  (Fig.  131)  from 
the  pleural  cavity  both  air  and  pus,  thus  partially  establishing  a  vacuum. 
This  procedure  favors  lung  expansion  and  is  a  great  aid  to  rapid  con- 
valescence.    A  suction  cup  may  be  similarly  used. 

The  duration  of  drainage  in  these  cases  varies  with  the  condition 
of  the  patient,  the  amount  of  pleural  or  lung  disease,  and  the  surround- 
ings. Dust-free  air,  as  in  the  country  or  at  the  seashore,  together  with 
maximum  sunshine,  are  the  best  tonics. 

Complications  and  Sequelae. — (i)  Lack  of  Free  Drainage. — 
If  the  characteristic  fluctuations  of  the  chart  persist  after  operation 
(see  Fig.  21,  p.   56),   an  encapsulated  empyema,  not  drained  by  the 


4o6 


OPERATIONS    ON    THE    THORAX 


operation,  is  to  be  suspected.  Sometimes  a  finger  can  be  introduced 
through  the  wound  to  break  up  the  adhesions  and  so  drain  such  a  cavity; 
at  other  times,  a  second  opening  must  be  made.     The  possibiHty  of 


Fig.  130. — Empyema. 
Sealing  in  a  tube,  througli  which  at  intervals  negative  pressure  is  produced  by  a  reversed  sjTinge-bulb. 

empyema  on  the  other  side,  although  rare,  must  always  be  kept  in 
mind.     Should  this  arise,  immediate  operation  might  best  be  attempted 


Fig.  131. — Empyema. 
Suction  used  to  encourage  lung-expansion. 


in  the  negative  pressure  cabinet.  It  may  be  conservative  to  carry  the 
operation  along  for  a  time  by  aspiration  of  the  second  side  until  the 
lung  on  the  first  side  has  expanded  somewhat. 


EMPYEMA 


407 


Encapsulated  empyema,  which  is  not  reached  by  operation,  apart 
from  the  chance  of  death  from  toxemia,  may  at  any  time  rupture  into 
a  bronchus  or  through  the  diaphragm  into  the  peritoneum  or  into  an 
adherent  colon.  ^ 

(2)  Sepsis  in  the  wound  is  always  present,  and  is  of  litde  importance, 
unless  the  pus  burrows  into  the  layers  of  the  chest-wall.  This  is  more 
liable  to  happen  if  the  opening  has  been  made  so  far  back  toward  the 
tip  of  the  scapula  as  to  go  through  the  latissimus  dorsi.  Any  such 
spread  of  infection  must  be  drained. 

(3)  Subcutaneous  emphysema  may  occur  if  the  inner  end  of  the  tube 
slips,  or  the  tube  gets  plugged  and,  at  the  same  time,  there  is  a  w^ound 
in  the  lung  sufficient  to  allow  air  to  be  forced  into  the  pleural  cavity  with 
each  inspiration. 

(4)  Cardiac  Dilatation. — Collapse  and  death  due  to  this  condition 
are  most  likely  to  occur  at  the  moment  of  escape  of  pus  during  the  opera- 
tion, particularly  in  left-sided  empyema,  when  the  heart  has  been  dis- 
located toward  the  right  and  suddenly  assumes  its  normal  position. 
Preventive  treatment  is,  of  course,  the  most  important.  The  pus  in 
left-sided  operation,  with  dislocation  of  the  heart,  should  be  allowed 
to  escape  slowly,  the  cardiac  condition  being  followed  closely  at  the 
same  time  with  stimulants  at  hand. 

(5)  Necrosis  of  Rib. — The  cut  ends  of  the  rib  or,  in  simple  pleur- 
otomy,  the  edge  of  rib  exposed,  may  become  necrotic,  beginning  with 
destruction  of  its  periosteum.  No  active  measures  of  treatment  should 
be  undertaken  until  the  empyema  itself  has  practically  stopped  dis- 
charging. At  such  a  time — namely,  eight  to  thirteen  weeks — the  dead 
bone  surface  will  probably  separate  itself  and  then  heal  over. 

(6)  Cerebral  abscess  is  spoken  of  as  a  possible  complication  of  em- 
pyema. There  is,  apparently,  little  in  the  literature  to  support  this 
view.  In  abscess  of  the  lung,  however,  we  find  a  not  infrequent  asso- 
ciation with  cerebral  abscess. 

(7)  Chronic  Sinus  and  its  Scquelce. — Where  failure  to  heal  seems 
to  depend  upon  failure  of  the  lung  to  reexpand,  treatment  b^  valve  or 

^  I  recently  saw  a  case  of  this  sort  with  Dr.  W.  W.  Harvey,  of  Boston.  The  right  chest 
had  been  flat  to  percussion,  but  an.  hour  later  became  tympanitic,  and  at  the  same  time 
great  reUef  of  all  symptoms  appeared,  accompanied  by  a  thin  yellow  diarrhea.  Three  days 
later  a  new  collapse  occurred,  with  profuse  discharge  from  the  trachea  of  thin,  yellow, 
foul-smeUing  material  and  symptoms  as  of  drowning.  At  the  same  time  distention  of 
the  abdomen  appeared,  increasing,  apparently,  with  almost  every  breath.  Autopsy  two 
Tiours  later  showed  an  encapsulated  empyema,  ruptured,  first,  through  diaphragm  into 
transverse  colon,  and  second  into  a  large  bronchus.  Every  deep  inspiration,  favored  by 
-valve-like  action  of  the  torn  lung,  served  to  blow  up  the  colon. 


4o8  OPERATIONS    ON    THE    THORAX 

suction  apparatus  is  indicated  (Fig.  131).  This  is  especially  of  value  in 
the  more  chronic  cases. 

Deformity  of  the  chest  is  usually  temporary  and  yields  to  treat- 
ment, but  long-continued  discharge  from  the  cavity  is  not  infrequently 
followed  by  chest  deformity  and  scoliosis  of  a  severe  type,  permanent 
and  sometimes  extremely  severe. 

(8)  Actinomycosis. — Ochsner^  says:  "In  the  United  States  empyema 
caused  by  an  infection  with  the  ray-fungus  is  not  so  very  uncommon, 
and  should  constantly  be  borne  in  mind  as  one  of  the  possibilities, 
especially  as  the  treatment  must  be  entirely  different  in  case  actinomy- 
cosis is  present.  This  condition  can  be  recognized  by  the  presence  of 
little  yellowish  flakes  in  discharge  from  the  empyema  which  contain  the 
characteristic  ray  fungus,  easily  demonstrated  by  microscopic  examiaati on. 

"In  cases  suffering  from  actinomycosis  it  is  important  to  bear  in 
mind  the  fact  that  this  disease  is  curable  by  the  administration  of  very 
large  doses  of  iodid  of  potash.  Sm.all  doses  are  of  little  benefit.  It 
seems  necessary  to  saturate  the  blood  thoroughly  with  this  drug  in 
order  to  destroy  the  parasite.  The  method  consists  in  the  administra- 
tion of  60  to  90  gr.  of  iodid  of  potash  in  a  glass  of  warm  milk  an  hour 
after  meals,  three  times  a  day,  followed  by  a  pint  of  hot  water.  In  this 
way  the  drug  can  be  given  in  these  large  doses  without  causing  any 
marked  disturbance.  It  is  used  for  three  days  in  succession,  then  the 
patient  is  permitted  to  rest  for  the  same  period  of  time,  when  the  ad- 
ministration is  again  repeated.  After  about  six  wrecks  of  treatment 
these  cases  usually  recover  perfectly  unless  an  undrained  abscess  be 
present.  In  such  case  some  of  the  parasites  seem  to  remain  where  the 
drug  does  not  reach  thehi,  and  from  that  point  a  reinfection  may 
take  place;  consequently,  it  is  wise  to  repeat  the  treatment  a  number 
of  times  after  permitting  the  patient  to  rest  for  a  month  or  two,  when 
he  has  arrived  at  what  is  considered  a  complete  cure." 

ABSCESS  OF  THE  LUNG 

The  abscess  cavity,  draining  through  the  external  wound,  should 
be  washed  or  wiped  out  with  tincture  of  iodin^  unless  too  much  coughing 
is  caused  by  it,  or  menthol  and  eucalyptus,  or  some  mild  antiseptic  and 
deodorant,  often  enough  to  control  the  bad  odor.  A  soft  tube  must  be 
maintained  to  the  very  depth  of  the  cavity  to  insure  healing  from  the 
bottom.  The  external  opening  tends  to  heal  before  the  lung  cavity  is 
obUterated,  If  this  happens,  bronchitis  or  bronchopneumonia  follows 
at  once. 

*  Clin.  Surg.,  1902,  272. 


GUNSHOT    AND    STAB    WOUNDS    OF    THE    CHEST  409 

THORACOPLASTY 
(Estlander's    Operation ;    Schede's    Operation) 

After  this  operation,  which  is  supposed  to  favor  the  collapse  of  the 
firm  chest-wall  enough  to  obliterate  a  pleural  cavity  into  which  the 
lung  will  not  expand,  there  are  no  special  directions  for  the  care  of 
the  woTind.  The  wound  is  packed  with  gauze,  and  the  cavity  which 
remains  is  sponged  every  day  or  two  with  full-strength  tincture  of  iodin, 
which  acts  in  these  cases  almost  as  a  specific.  This  operation  is  not 
usually  performed  until  every  effort  is  made  to  aid  the  lung  to  expand. 

For  details  as  to  recent  progress  of  lung  surgery  under  positive  and 
negative  pressure,  reference  is  made  to: 

Samuel  Robinson,  Experimental  Surgery  of  Lungs,  Ann.  Surg.,  1908;  xlvii,  185;  Arti- 
ficial Intrapulmonary  Positive  Pressure,  Jour.  Amer.  Med.  Assoc,  1908,  li,  803;  Surgical 
Aspects  of  Tuberculosis  of  Lungs  and  Pleura,  Trans.  VI.  Internat.  Cong.  Tuberc,  1908, 
73.  Samuel  Robinson  and  G.  A.  Leland,  Jr.,  Surgery  of  Lungs  under  Positive  and  Nega- 
tive Pressure,  Surg.  Gyn.  and  Obstet.,  1909,  255. 

These  articles  also  contain  complete  bibliographies. 

OPERATIONS  ON  THE  PERICARDIUM 

A  punctured  wound  of  the  pericardium,  as  from  a  trocar  for  relief 
of  effusion,  is  sealed  at  once  with  cotton  and  collodion.  Where  pus  is 
present,  with  the  trocar  as  a  guide,  a  free  incision  is  made  and  drainage 
maintained  through  a  soft-rubber  tube  held,  to  prevent  slipping  in  or 
out,  by  a  stitch  through  i.t  and  the  skin.  The  inch  or  more  of  tubing 
which  is  within  the  pericardium  should  be  fenestrated,  and  after  the 
dressing  is  applied  drainage  of  the  cavity  may  be  materially  aided  by 
keeping  the  patient  lying  face  down  as  much  as  possible. 

Cardiac  stimulation  should  be  used  in  these  cases  only  for  reason, 
for  it  should  be  constantly  in  mind  that  the  heart  may  be  doing  its  best. 

GUNSHOT  AND  STAB  WOUNDS  OF  THE  CHEST 

"  la  the  treatment  of  gunshot  or  stab  wounds  of  the  chest  it  is,  first, 
important  to  determine  whether  there  is  dangerous  bleeding  from  the 
intercostal  vessels  or  from  the  internal  mammary  artery.  The  former 
can  easily  be  exposed,  clamped,  and  ligated.  The  latter,  being  located 
near  the  sternum,  between  the  costal  cartilages  and  the  pleura,  is  in  a 
position  in  which  it  is  difficult' to  ligate  without  fear  of  causing  pneumo- 
thorax by  opening  the  pleura.  The  fact  that  this  vessel  is  given  off  from 
the  subclavian  artery  makes  the  hemorrhage  very  formidable,  and  the 
fact  that  it  is  located  behind  the  costal  cartilages  makes  a  hemorrhage 
into  the  pleural  cavity  more  likely  than  an  external  hemorrhage.  In 
case  of  bleeding  from  the  internal  mammary  artery  it  is  necessary  to 


4IO  OPERATIOXS    OX    THE    THORAX 

bear  in  mind  tiie  fact  that  the  costal  cartilage  can  be  easily  cut  with  an 
ordinary  scalpel  and  that  the  external  wound  is  of  no  importance,  con- 
sequently a  large  external  wound  should  be  made  over  the  costal  carti- 
lage of  the  next  rib  about  the  point  of  injury;  this  cartilage  should  be 
carefully  cut  away  for  a  distance  of  at  least  an  inch  over  the  point  at 
vhich  it  crosses  the  artery,  and  then  a  fine  stitch  should  be  passed 
around  the  artery  and  tied.  The  danger  from  trying  to  perform  this 
operation  through  a  small  external  wound  is  very  much  greater  than  it 
is  if  ample  space  be  secured  by  making  a  large  external  wound. 

"The  hemorrhage  from  these  two  sources  having  been  disposed  of, 
the  next  important  point  is  to  secure,  as  nearly  as  possible,  complete  rest 
of  the  chest-walls.  This  can  best  be  accomplished  by  applying  a  plaster- 
of-Paris  jacket,  extending  from  the  lower  border  of  the  ribs  up  over  both 
shoulders.  The  patient  will  immediately  begin  to  breathe  by  using 
the  diaphragm  alone,  and  the  irritable  hacking  cough  will  in  most  cases 
subside,  and,  therefore,  the  patient  will  stop  pumping  blood  from  the 
lung  tissue  into  his  pleural  cavity.  If  empyema  follows  through  an 
infection  caused  by  the  injury,  it  should  be  treated  according  to  the 
method  which  has  already  been  detailed. 

"This  point  should  be  borne  in  mind  above  all  things — that  under 
no  condition  should  a  Avound  of  the  thorax  be  examined  with  a  probe, 
because  probing  is  one  of  the  chief  sources  of  infection.  If  plaster  of 
Paris  is  not  available,  or  if  the  patient  does  not  seem  sufficiently  strong 
to  bear  its  application,  a  protecting  cast  can  be  constructed  in  a  few 
minutes  by  winding  long  strips  of  rubber  adhesive  plaster,  from  2  to 
3  inches  in  width,  about  the  entire  chest,  beginning  at  the  border  of  the 
ribs  and  working  upward  until  the  whole  chest  and  shoulders  are  covered. 
Several  layers  of  this  plaster  may  be  applied  to  advantage.  It  is  sur- 
prising how  quickly  a  patient,  who  has  not  been  able  to  rest  for  a  moment 
on  account  of  the  irritation  due  to  the  motion  of  his  chest-walls,  will 
become  quiet  and  fall  asleep  after  one  or  the  other  of  these  jackets  has 
been  applied.  Cases  which  have  so  far  advanced  that  the  danger  of 
new  hemorrhJage  is  over,  but  in  which  the  blood  in  the  pleural  caxity 
is  not  absorbed,  should  be  aspirated  through  a  trocar  or  drained  by  open 
incision  or  treated  hke  an  empyema."  ^ 

If  the  symptoms  are  not  those  of  hemorrhage,  the  wound  is  to  be 
cleaned  and  sealed.  ^Mechanical  rest  and  morphin  are  used  to  diminish 
the  respiratory  excursion  and  to  lessen  the  chance  of  secondary  hemor- 
rhage. 

^  Ochsner,  Clin.  Surg.,  1902,  pp.  277,  278. 


CHAPTER  XLIV 
OPERATIONS  ON  THE  ABDOMEN 

GASTRO-ENTEROSTOMY 

"  On  being  placed  in  bed  a  glass  female  douche  point  is  passed  just 
above  the  internal  sphincter  and  attached  to  a  gravity  bag  filled  with 
half-strength  normal  salt  solution.  The  elevation  should  not  be  greater 
than  6  inches.  A  small  stream  passed  into  the  rectum  is  easily  absorbed 
without  irritation.  One  or  two  quarts  are  taken  up  in  an  hour.  The 
patient  is  then  placed  in  a  semisitting  posture.  Beginning  at  sixteen  to 
twenty  hours,  an  ounce  of  hot  water  is  given  every  hour;  this  is  rapidly 
increased,  and  in  thirty-six  hours  the  usual  experimentation  with  liquid 
feeding  is  instituted.  Rectal  feeding  is  unnecessary."  ^  The  patient 
may  get  up  on  the  fourth  to  tenth  day,  according  to  his  strength. 

Recent  investigations  ^  have  established  '  the  fact  that  a  gastro- 
enterostomy opening  will  not  functionate  unless  there  is  some  obstruc- 
tion to  the  normal  outlet  at  the  pylorus.  This  is  due  to  the  fact  that 
the  pylorus  is  situated  at  the  most  dependent  part  of  the  stomach,  that 
peristaltic  action  directs  the  stomach-contents  toward  the  pylorus,  and 
that  peristalsis  tends  to  close  the  anastomotic  opening.  If  there  is  tem- 
porary closure  of  the  pylorus  from  spasm,  as  in  cases  of  gastric  ulcer, 
the  gastro-enterostomy  opening  will  remain  patent  until  the  normal 
acidity  of  the  gastric  juices  has  been  attained. 

After  every  com^petent  gastro-enterostomy,  bile  and  pancreatic 
secretion  will  be  found  in  the  stomach,  in  amounts  depending  on  the 
style  of'  operative  procedure  and  the  sufficiency  of  the  opening.  In 
cases  of  permanent  closure  of  the  pylorus,  this  finding  will  persist,  and, 
so  far  as  present  observations  go,  it  does  not  seem  to  interfere  appreciably 
with  gastric  digestion  and  nutrition.  If  it  disappears,  it  means  that 
the  pylorus  is  resuming  its  function,  under  the  encouragement  of  the 
neutralized  hyperacid  gastric  juices. 

Complications  and  Sequelae. — Peritonitis  is  rare  with  a  sur- 
geon skilled  in  the  technique.    If  it  develops,  the  wound  must  be  opened, 

^  W.  J.  Mayo,  Five  Hundred  Cases  of  Gastro-enterostomy,  Ann.  Surg.,  1905,  xHi,  641. 
^  See  especially  W.  B.  Cannon,  Boston  Med.  and  Surg.  Jour.,  1909,  clvi,  720. 

4U 


412  OPERATIONS    ON    THE   ABDOMEN 

the  cavity  washed  out,  and  drained  at  site  of  operation  and  elsewhere  if 
it  seems  best. 

Delayed  hemorrhage  should  be  equally  unexpected. 

Acute  intestinal  obstruction  or  gastric  dilatation  may  occur  from 
kinks  or  adhesions.  In  a  case  of  Bloodgood's  ^  a  loop  of  jejunum  was 
found  caught  in  the  fossa  of  Treitz. 

Persistent  vomiting,  not  obstructive,  persisting  partly  from  habit, 
may  be  a  serious  sequel  of  operation.  The  treatment  varies  from 
stomach  starvation  to  giving  the  patient  whatever  he  wants.  A  case  of 
mine  vomited  everything  until  she  demanded  and  got  broiled  beefsteak. 

If  the  vomiting  does  not  stop,  and  bile  is  found  in  the  vomitus,  the 
surgeon  must  conclude  that  a  vicious  circle  has  been  established,  whereby, 
on  account  of  a  kink  or  valve  fold  at  the  enterostomy  site,  or  obstruc- 
tion beyond,  all  the  bile  and  pancreatic  juice  is  flowing  back  through  the 
gastro-enterostomy  into  the  stomach.  In  the  early  days  of  the  opera- 
tion when  a  long  loop  (9  in.)  was  used,  this  was  frequent.  At  present 
with  the  jejunal  loop  of  minimum  length  or  with  the  Roux  operation  this 
is  less  likely  to  occur.  The  only  treatment  is  a  secondary  operation  to 
modify  the  first. 

Jejunal  and  Gastrojejunal  Ulcer. — The  possibility  of  such  ulceration 
following  this  operation  should  always  be  in  the  surgeon's  mind.  A 
very  thorough  research  on  the  subject  has  been  made  by  Prof.  Herbert 
J.  Patersonof  London.^  He  reports  2  cases  and  has  collected  61  others. 
He  summarizes  the  views  as  to  the  causes  of  these  ulcers  after  gastro- 
enterostomy thus: 

I.  Hyperacidity,  normal  flow  of  bile  and  pancreatic  juice. 

II.  Normal  acidity  or  hypersecretion,  normal  flow  of  bile  and  pan- 
creatic juice. 

III.  Normal  acidity,  diminished  flow  or  diversion  of  bile  and  pancre- 
atic juice, 

IV.  Normal  acidity,  normal  flow  of  bile  and  pancreatic  juice.  Toxic 
agent  other  than  HCl. 

V.  Infective  processes. 

Research  on  the  first  two  of  these  causes  has  been  made  by  Dr. 
Charles  Bolton.^  He  says:  "It  appears  that  any  strength  of  HCl  above 
the  normal  can  act  as  a  protoplasmic  poison  for  the  gastric  cells  and 
Avill  add  its  quota  to  other  devitalizing  influences  and  assist  in  bringing 
about  self-digestion." 

^Ann.  Surg.,  1903,  xxxviii,  806. 

"  Jejunal  and  Gastrojejunal  Ulcer  Following  Gastrojejunostomy,  Ann.  Surg.,  1909,  1, 
367.  ^  Bolton,  Trans.  Royal  Soc.  Med.,  Dec,  1908,  Path.  Sect.,  p.  54. 


GASTROSTOMY  413 

It  is  true  that  it  has  been  asserted  that  the  inner  row  of  stitches  in 
the  anastomosis  on  animals  seems  to  have  httle  influence  on  the  heahng. 
The  mucous  membrane  around  the  margin  sloughed,  leaving  an  ulcer 
which  covered  over  in  about  three  weeks.  If  this  were  true  on  the  human, 
every  case  is  followed  by  a  gastrojejunal  ulcer.  Mr.  Paterson  believes, 
in  my  judgment  rightly,  that  in  humans  primary  union  is  possible  through 
the  sterilizing  of  the  gastro-intestinal  tract  in  preparation  and  the  com- 
pletely aseptic  technique.  He  is  supported  in  this  belief  by  the  fact 
that  microscopic  examination  from  recent  anastomoses  have  not  shown 
such  sloughing.  He  holds,  further,  that  "regurgitation  of  bile  and 
pancreatic  juice,  which  takes  place  into  the  stomach  after  simple  gastro- 
jejunostomy, must  be  favorable  to  the  union  of  the  apposed  surfaces  by 
diminishing  the  acidity  of  gastric  contents  as  they  pass  through  the 
opening."  He  declares  that  in  24  per  cent,  of  the  recorded  cases  jejunal 
ulcer  has  followed  operation  of  the  Y-type  (Roux  operation).  Pater- 
son's  conclusions  on  the  subject  seem  worthy  of  quotation. 

"  The  necessity  for  prolonged  after-treatment  in  cases  of  gastrojejunostomy 
has  perhaps  not  received  the  attention  which  it  desen-'es.  My  rule  is  to 
advise  all  patients  whose  gastric  contents  have  been  hyperacid  before  gastro- 
jejunostomy, to  avoid  meat  in  any  form  for  six  months  at  least,  and  until 
such  time  as  examination  shows  that  the  gastric  acidity  is  subnormal.  The 
immediate  relief  which  is  experienced  by  patients  on  whom  gastrojejunostomy 
has  been  performed,  tempts  them  to  indulge  in  food  unsuited  to  the  condition 
of  the  gastric  mucosa.  In  most  cases  in  which  gastrojejunostomy  is  neces- 
sary, the  mucous  membrane  is  chronically  inflamed,  and  many  months 
must  elapse  before  it  is  restored  to  a  healthy  condition. 

"  Some  surgeons,  in  their  dread  of  jejunal  ulcer,  have  maintained  that 
gastrojejunostomy  is  contraindicated  in  gastric  ulcer  \\dth  hyperacidity, 
except  when  the  ulcer  is  near  the  pylorus  and  is  causing  symptoms  of  obstruc- 
tion. Others  have  even  suggested  that  unless  there  be  gastric  stasis,  gastro- 
jejunostomy is  useless  in  the  treatment  of  gastric  ulcer.  I  beUeve  this  teach- 
ing to  be  retrogressive.  For  some  years  I  have  been  advocating  the  view 
that  gastrojejunostomy  is  not  a  drainage  operation. 

"  The  success  which  follows  this  operation  in  cases  of  gastric  ulcer  is  due, 
not  to  drainage,  but  to  the  physiologic  effects  of  the  operation  in  diminish- 
ing the  acidity  of  the. gastric  contents,  and  this  diminution  follows  gastro- 
jejunostomy irrespective  of  the  situation  of  the  ulcer." 

GASTROSTOMY 

In  this  operation,  whatever  type  has  been  used,  either  the  simplest 
or  one  of  the  complex  ones,  in  which  an  attempt  is  made  to  establish 
the  valve-like  opening,  it  is  well  to  leave  a  tube  tied  in  through  the  gas- 


414  OPERATIONS    ON    THE    ABDOMEN 

trostomy  at  the  end  of  operation  in  order  that  for  feeding  the  first  few 
days  the  abdominal  wound  need  not  be  disturbed.  This  tube  of  soft 
rubber,  held  from  slipping  for  the  time  being  by  a  single  catgut  stitch, 
comes  out  of  itself  at  the  end  of  a  week  or  ten  days.  After  this  a  funnel 
or  stomach-tube  with  funnel  is  passed  into  the  gastrostomy  opening  at 
each  meal  time.  Through  the  opening  then  is  introduced  at  the  ap- 
propriate time  first  the  usual  postoperative  diet,  very  rapidly  increasing 
to  the  full  limit  of  the  patient's  digestion.  If  the  esophageal  obstruc- 
tion has  been  so  complete  that  the  patient  suffered  severely  from  thirst 
before  the  operation,  half  a  pint  of  warm  normal  salt  solution  may 
be  poured  into  the  stomach  through  the  feeding-tube  at  the  end  of  the 
operation,  and  this  should  be  repeated  every  half-hour  until  the  thirst 
is  satisfied.  If  he  has  been  able  to  drink  before  operation,  he  may  be 
allowed  to  do  so  afterward  if  this  causes  no  distress;  otherwise,  fluid  is 
to  be  given  through  the  feeding-tube  only.  After  a  time  the  absence 
of  irritation  may  cause  the  obstruction  to  be  less  complete,  and  then  the 
patient  again  will  be  able  to  take  liquids  by  mouth.  The  ideal  prepara- 
tion of  food  for  a  gastrostomy  is  in  the  patient's  mouth,- and  there  are 
many  instances  in  the  literature  reported  of  patients  who  chew  their 
food,  subject  it  thereby  to  salivary  digestion,  and  by  their  enjoyment 
of  it  stimulate  gastric  digestion.  They  then  eject  the  food,  well  chewed, 
into  the  funnel^  whence  it  passes,  if  the  opening  is  big  enough,  directly 
into  the  stomach. 

"  Almost  invariably  these  patients  gain  rapidly  in  weight  and  strength, 
because  the  enforced  rest  of  the  stomach  and  intestines  has  usually 
placed  these  organs  in  a  condition  in  which  they  can  thoroughly  digest 
an  abundance  of  food.  I  have  repeatedly  obser\-ed  these  sufferers  gain 
sufficiently  in  strength  in  a  few  weeks  to  enable  them  to  do  hard  manual 
labor,  which  they  continued  to  do  until  the  carcinoma  had  implicated  some 
other  important  organ,  either  by  invasion  or  by  the  formation  of  metas- 
tases. 

"It  is,  of  course,  necessary  to  explain  to  the  friends  of  the  patient 
that  this  operation  cannot  result  in  a  cure  of  the  disease,  but  that  it  can 
simply  give  temporary  relief.  This  relief,  however,  is  so  great,  and 
the  risk  in  obtaining  it  is  so  slight,  that  it  is  an  operation  which  can  be 
very  strongly  recommended.  Aside  from  the  distress  due  to  hunger, 
and  especially  to  thirst,  patients  afflicted  with  obstruction  of  the  eso- 
phagus suffer  pain  but  slightly,  consequently  the  relief  given  by  this 
operation  is  relatively  very  complete."^ 

In  benign  stricture  of  the  esophagus  a  bougie  should  be  passed  at 

^  Ochsner,  Clin.  Surg.,  1902,  pp.  179,  iSo. 


GASTRECTOMY 


415 


least  once  a  month  during  the  remainder  of  the  patient's  life,  in  order 
to  prevent  a  late  contracture,  which  may  otherwise  come  on  so  gradually 
that  the  patient  does  not  recognize  it  until  so  far  advanced  that  it  is 
difi&cult  to  dilate  it  again. 

Complications  and  Sequelae.— I.  Intense  pain  on  the  intro- 
duction of  food  into  the  stomach.  Several  instances  of  this  have  been 
noted,  but  it  seems  as  if  in  each  case  the  cause  may  have  been  lack  of 
fine  division  or  grinding  of  the  food  or  the  too  rapid  attempts  to  take 
full  diet  after  many  weeks  or  months  of  starvation. 

II.  Acute  gastritis  is  really  an  exaggerated  form  of  what  has  just 
been  noted.  It  is  an  acute  gastric  indigestion  following  lack  of  careful 
gradation  in  extending  the  diet  list  after  long  fasting. 

III.  Inanition  and  Exhaustion. — The  operation  may  be  postponed 
until  the  patient  is  in  such  a  state  that  he  is  too  weak  to  rally. 

IV.  Sepsis  may  appear  after  any  such  operation  either  in  the  form 
of  a  general  peritonitis  or  as  localized  abscess  between  the  stomach  and 
the  liver,  or  on  the  other  side  behind  the  spleen. 

GASTRECTOMY 

This  unusual  and  rather  dramatic  operation,  after  the  results  of 
hemorrhage  and  shock  have  been  met,  presents  only  the  problem  of 
feeding.  If  the  loss  of  blood  has  been  considerable,  transfusion  may 
be  done,  and  in  practically  every  case  saline  under  the  breasts  is  to  be 
used.  Food  is  given  on  the  second  or  third  day  with  much  less  hesita- 
tion than  formerly.  For  example,  Ehrlich^  recommends  the  following 
diet:  First  day,  tea,  red  wine,  broths;  second  day,  bouillon  with  bits  of 
meat;  following  days,  chopped  chicken,  beef,  lamb,  potato  soup,  eggs; 
seventh  day,  ordinary  diet,  but  made  up  of  things  easy  to  digest.- 

Total  gastrectomies  take  their  nourishment  in  small  amounts  at 
short  intervals;  thus,  the  case  of  Schlatter  ^  took  food  every  three  hours 
at  first,  and  in  the  fourth  week  w-as  taking  a  full  variety  of  food.  Eight 
months  after  the  operation  this  case  was  eating  like  any  healthy  person. 
Gradual  increase  in  the  amount  leads,  apparently,"  to  a  dilatation  of  the 
region  near  the  union  of  esophagus  and  duodenum.* 

^Rev.  Franjaise  Med.  et  Chir.,  1905,  761. 

^  A.   Monprofit,  La  Gastrectomie,  Paris,  1908,  119. 

^Beit.  z.  klin.  Chir.,  1898,  xix,  757. 

*Dr.  Harvie,  of  New  York  (Ann.  Surg.,  March,  1900,  p.  344),  reports  a  case  of 
gastrectomy  where  duodenum  and  esophagus  were  united  by  direct  suture.  The  patient 
was  a  woman,  aged  forty-six,  who  had  had  gastric  symptoms  for  eighteen  months  before 
operation.  On  examination  a  rounded  tumor  could  both  be  seen  and  felt.  The  opera- 
tion was  rendered  difficult  by  adhesions  both  in  front  and  behind  the  stomach,  practic- 
ally the  whole  of  which  was  infiltrated  and  thickened.     The  entire  stomach  was  removed 


41 6  OPERATIONS    ON    THE    ABDOMEN 

Complications  and  Sequelae. — (i)  Constipation. — For  a  time, 
at  least,  there  is  a  greatly  diminished  gastric  digestion,  and  a  consid- 
erable quantit}'  of  material  usually  digested  in  the  stomach  is,  there- 
fore, passed  on  to  the  intestine  without  alteration.  The  resulting  con- 
stipation is  usually  not  of  long  duration. 

(2)  Diarrhea  may  appear  for  exactly  the  same  reason. 

(3)  Stasis. — When  feeding  is  first  begun  after  operations  near  the 
pyloric  end  of  the  stomach,  motility  of  the  stomach  may  be  so  much 
diminished  that  stasis  with  decomposition  of  food  will  appear.  This 
should  be  suspected  if  there  is  a  distressed  feeling  or  sensation  of  weight 
in  the  stomach  region  or  vomiting  of  fetid  material.  Indeed,  sometimes 
high  fever  may  be  the  only  symptom.  For  this  the  stomach  should  be 
washed  out.  The  tube  should  be  passed  very  gently,  and  after  it  enters 
the  stomach  region,  the  water  pressure  should  be  very  low.  Nothing 
approaching  distention  should  be  permitted. 

(4)  Infection. — The  possibility  of  this  ranges  from  infection  of  the 
abdominal  wound  up  to  general  peritonitis,  and  calls  for  no  treatment 
not  already  outlined. 

PYLOROPLASTY 

Finney  ^  c^uotes  Robson  as  follows : 

^'Concerning  Points  in  Favor  of  Pyloroplasty. — (i)  Regurgitation 
of  bile  into  the  stomach  is  prevented. 

"  (2)  Secretion  of  hydrochloric  acid,  when  it  has  been  excessive, 
becomes  normal. 

"  (3)  If  the  secretion  of  hydrochloric  acid  has  been  diminished  or 
absent  before  operation,  it  remains  in  statu  quo  after  operation. 

"  (4)  If  there  has  been  primary  gastric  atony,  peristalsis  is  but  little 
improved. 

"  (5)  This  function  improves  rapidly,  or  reaches  perfection,  if  the 
muscular  contractility  has  been  normal  or  increased  and  when  the 
obstruction  was  due  to  fibrous  stenosis  or  pyloric  spasm. 

"  (6)  In  all  such  cases  evacuation  of  the  stomach  is  accomplished  in 
its  physiologic  period,  except  in  rare  cases,  and  these  only  in  the  first 
months  after  operation. 

and  the  cut  surfaces  of  esophagus  and  duodenum  united  by  means  of  sutures.  The 
entire  time  consumed,  from  the  first  incision  till  the  abdomen  was  closed,  was  one  hour 
and  five  minutes.  There  was  little  or  no  loss  of  blood.  Subsequent  progress  was  most 
satisfactory,  nourishment  being  given  by  the  mouth  on  the  eighth  day.  The  patient  left 
the  hospital  six  weeks  after  the  operation  after  taking  a  dinner  consisting  of  roast  beef, 
mashed  potatoes,  ice-cream,  cup  of  coffee,  and  one  glass  of  milk.  (Quoted  by  Mr.  Jacob- 
son,  vol.  ii,  p.  326.) 

^  Johns  Hopkins  Hosp.  Bull.,  1902,  xiii,  157. 


GASTROPLICATION 


417 


"  (7)  Capacity  of  the  stomach  ahvays  decreases,  but  rarely  becomes 
as  small  as  normal. 

"  (8)  The  pylorus  recovers  tone. 

"Points  of  Difference  Between  tJie  Results  of  Pyloroplasty  and  Gastro- 
enterostomy.— (i)  The  absence  of  regurgitation  of  bile,  and  hence 
absence  of  any  biliary  influence  on  the  gastric  secretions. 

''  (2)  The  function  of  the  stomach  is  not  accelerated,  hence  the  difiS- 
cult}^  the  stomach  has  in  reaching  its  normal  size. 

"  (3)  Slight  or  negative  result  obtained  by  pyloroplasty  in  abstract 
from  primary  gastrectomy  compared  to  the  positiA^e  results  from  pos- 
terior gastro-enterostomy." 

Finney  now  continues: 

"  x\ccumulated  experience  has  proved  that  it  is  unnecessary  and 
often  harmful  to  put  patients  through  a  long  course  of  preliminary 
treatment.  Cleaning  the  mouth  and  teeth  carefully  with  antiseptic 
washes  and  the  administration  of  sterile  food  only  will  quickly  render 
the  stomach-contents  innocuous.  The  treatment  carried  out  in  all  my 
cases  was  as  follows: 

"For  t^vo  or  three  days  before  the  operation  the  mouth  and  teeth 
were  carefully  cleaned  with  carbolic  solution  and  only  sterile  liquid  food 
and  water  administered.  The  stomach  was  irrigated  night  and  morning 
just  before  operation  with  boiled  water.  No  food  at  all  was  given  by 
mouth  for  twelve  hours  preceding  operation.  Cultures  were  taken  from 
the  stomach-contents  in  three  of  the  cases  and  two  were  found  to  be 
sterile.  The  abdominal  wound  is  closed  without  drainage.  Nothing 
is  given  by  mouth  for  the  first  thirty-six  to  forty-eight  hours.  Enemata 
of  salt  solution  and  coffee  are  given  every  five  hours  for  the  first  t\venty- 
four  hours,  after  which  time  nutrient  enemata  are  alternated  with  the 
salt  solution.  Water  in  small  quantities  is  allowed  early.  On  the  second 
or  third  day  albumin  in  teaspoonful  doses  is  administered,  and,  if  borne 
well,  broths  and  milk  are  rapidly  added. 

"  Patients  are  not  required  to  lie  flat  on  the  back,  but  are  encouraged 
to  turn,  and  even  allowed  to  be  propped  up  in  bed  very  soon  after  the 
operation." 

GASTROPLICATION 

This  operation  is  to  be  done  "only  in  the  very  rare  cases  of  so-called 
idiopathic  dilatation  of  the  stomach  accompanying  gastroptosis.  Since 
these  cases  will  usually  yield  to  lavage  and  general  health  improvement, 
the  operation  is  not  frequently  performed. 

Farquhar  Curtis^  says:  ''If  the  surgeon  should  chance  to  overlook 

^  Ann.  Surg.,  igoo    xxxii,  49. 
27 


41 8  OPERATIONS    ON    THE    ABDOMEN 

some  cause  of  pyloric  obstruction,  his  patient  will  be  sure  of  cure  if  he 
survives  the  operation,  whereas  gastroplication  will  be  useless  if  pyloric 
obstruction  exists." 

PYLORECTOMY 

Whether  direct  suture  of  the  first  portion  of  the  duodenum  to  the 
stomach  has  been  made,  or  closure  of  the  cut  ends  with  gastrojejun- 
ostomy, the  shock  is  profound,  and  the  principal  attention  during  early 
after-treatment  is  directed  to  meet  this  condition.  Beyond  that,  the  care 
is  practically  the  same  as  in  gastrojejunostomy.     (See  p.  411.) 

PERFORATED  GASTRIC  ULCER 

In  these  cases,  even  though  the  operation  has  been  performed  within 
a  very  few  hours  after  the  perforation,  drainage  is  to  be  employed. 
This  drainage  is  not  established  so  much  because  of  actual  infection 
of  the  peritoneum,  but  the  mere  escape  of  gastric  contents  sets  up  an 
irritation  which  reduces  the  resistance  of  the  peritoneum  and  gives 
every  favorable  condition  for  the  spread  of  an  infectious  process.  Tube 
drainage,  preferably  of  the  spiral  type,  should  go  dowm  to  the  site  of 
the  closed  ulcer,  and  also  to  the  region  of  the  right  kidney  and  over 
behind  the  spleen.  If  the  effusion  of  gastric  contents  has  been  general, 
it  will  probably  be  wise  also,  through  a  suprapubic  incision,  to  drain  the 
pelvis.  These  cases,  if  the  perforation  has  been  found  and  closed,  may 
be  given  water  at  the  end  of  twelve  to  eighteen  hours;  in  sma.ll  amounts 
at  first,  lest  vomiting  appear.  At  the  end  of  twenty-four  hours  feeding 
by  rectum  should  be  begun.  A  nutrient  enema  (see  p.  125)  should  be 
given  every  eight  hours  with  a  mild  soap-and-water  cleansing  enema 
two  hours  before  the  morning  nutritive.  As  in  the  case  of  all  drainage, 
the  watchful  "let  alone"  policy  is  here  also  to  be  followed.  The  wicks 
are  to  be  started  about  the  fourth  day  and  extracted  on  the  sixth  or 
seventh  day,  although  at  any  time  before  then  it  may  be  necessary  to 
remove  the  wicks  if  there  is  apparently  any  retention  of  pus  behind 
them.  With  the  extreme  danger  of  residual  abscess  in  some  fossas,  or  up 
under  the  dome  of  the  diaphragm,  continued  drainage  should  be  main- 
tained until  the  temperature  is  normal  and  the  pus  has  practically  dis- 
appeared. Klapp's  suction-bulbs  or  syringe  (see  p.  235)  may  be  used 
with  advantage.  Feeding  by  stomach  should  be  postponed  four  to 
six  weeks  if  the  rectum  will  endure  nutritive  enemas  for  so  long  a  time. 
The  starving  stomach  during  this  period,  particularly  as  ulcerated 
stomachs  are  usually  hyperacid,  may  be  the  source  of  attacks  of  heart- 
burn, repeated  perhaps  several  times  daily  to  a  distressing  degree. 


PERFORATED  GASTRIC  ULCER 


419 


Sodium  bicarbonate,  i  dr.  in  one-half  cup  of  water,  will  give  temporary 
and  sufficient  relief  to  the  symptom,  and  may  be  repeated  many  times 
with  no  bad  effects.     Practice  as  to  time  of  beginning  stomach-feeding 


Diagnosis    Perforated  Pyloric  Ulcer.                                          \ 

'^UW^liSiii 

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Fig.  132. — Perforation  of  Pyloric  Ulcer. 
Operation  eight  hours  later.     Stomach-contents  diffused  throughout  abdominal  cavity.    No  septic  reaction. 

after  perforation  varies  widely.     For  example.   Dr.   Jos.   A.   Blake  ^ 
remarks  on  a  case  of  perforated  gastric  ulcer  as  follows: 

"Albumin-water  was  given  on  the  day  after  operation.  On  the  third  day  the  patient 
was  given  whole  milk  that  had  been  coagulated  with  rennet  and  the  curd  then  beaten  mth 
an  egg-beater  and  pressed  through  cheese-cloth,  there  then  being  no  possibility  of  large 
curds  forming  in  the  stomach.  This  form  of  milk,  devised  by  Dr.  Walter  Martin,  has  been 
used  with  great  success  in  several  postoperative  stomach  cases,  and  is  far  more  palatable 
than  peptonized  milk." 

When  full  diet  is  resumed  after  operation  for  perforated  gastric 
ulcer,  I  allow  the  following  liberal  diet,  the  list  including  all  things  which 

^  Ann.  Surg.,  190S,  xlviii,  130. 


420 


OPERATIONS    ON    THE   ABDOMEN 


the  patient  may  eat.  The  important  rule  should  be  not  what  he  eats  so 
much  as  his  method  of  eating.  I  direct  that  the  food  shall  be  taken  dry 
and  that  each  mouthful  shall  be  chewed  till  it  is  fluid.  The  quantity 
will  then  regulate  itself:  too  much  will  not  be  eaten. 


Diet-list  Atter  Healing  of  Gastric  Ulcer,  to  Avoid  Recurrence. 


Soups  : 

Buttermilk, 

Mulled  wine. 

Purees  and  creams: 

Cream, 

'    Caudle, 

Barley, 

Boiled  milk, 

Broth  with  egg. 

Rice, 

Pasteurized. 

Pea, 
Potato, 

Butter. 

Puddings  : 
Blanc  mange. 

Tomato, 

Vegetables: 

Cup  custard. 

Asparagus, 

Starchy: 

Junket, 

Celery. 

Rice, 
Peas, 

Rice. 

Thick  soups: 

Lima  beans, 

Ice  Cream: 

Vegetable, 

Potatoes, 

Vanilla, 

Noodle, 

Baked, 

Chocolate, 

Julienne, 

Boiled, 

Fruit  flavors. 

Vermicelli, 

Mashed. 

Fish  soups. 

Water  Ices: 

Green  Vegetables: 

Orange, 

Fish: 

Tomatoes, 

Lemon, 

Broiled, 

Stewed, 

Sherberts. 

Boiled. 

Baked, 

Lettuce. 

Cake: 

Oysters: 

Plain. 

Raw, 

Bread  : 

Panned, 

Stale, 

Jellies: 

Broiled, 

Toasted, 

Lemon, 

Stewed, 

Pulled, 

Wine, 

Scalloped. 

Zwieback, 
White  flour. 

Fruit. 

Meats  : 

' Sugars  : 

Boiled, 

Cereals: 

Cane-sugar, 

Stewed, 

Corn  meal, 

Honey, 

Roasted, 

Hominy, 

Molasses, 

Broiled, 

Arrow-root, 

Confectionery. 

Hashed, 

Tapioca, 

Beef, 

Cornstarch, 

Fruits: 

Mutton, 

Farina, 

Oranges, 

Mutton  chops. 

Sago, 

Melons. 

Lamb, 

Macaroni, 

Lamb  chops. 

Spaghetti. 

Stewed: 
Apples, 

Poultry: 

Special: 

Peaches, 

Chicken, 

Beef-juice, 

Pears, 

Turkey, 

Clam-juice, 

Plums, 

"White  meat, 

Scraped  beef. 

Apricots, 

Squab. 

Beef-tea, 
Albumin -water, 

Cherries. 

Eggs: 

Milk  toast. 

Nuts: 

Soft  boiled. 

Toast-water, 

Peanuts. 

Poached, 

Barley-water, 

Scrambled, 

Gruel,  • 

Beverages 

Omelet. 

Irish  moss. 

(on  empty  stomach  only) 

Flaxseed  tea. 

Cocoa, 

Milk-punch, 

Lemonade, 

Milk: 

Eggnog, 

Grape-juice, 

Unskimmed, 

Koumiss, 

Mineral  waters. 

Skimmed, 

Wine  whey, 

COLOSTOMY  421 

PERFORATED  DUODENAL  ULCER 
In  cases  operated  within  ten  hours  the  peritonitis  is  here  as  in  gas- 
tric perforation,  also  largely  irritative  and  chemical  rather  than  septic. 
The  after-treatment   is  identical  with   that   of  gastric   perforation 
{vide  supra). 

COLOSTOMY 

This  subject  is  a  difficult  one  to  discuss  solely  from  the  point  of  view 
of  after-treatment,  since  so  many  possible  conditions  and  complications 
may  be  present,  depending  frequently  upon  the  great  possible  variety 
of  operations. 

If  the  operation  has  been  a  deliberate  one,  that  is  to  say,  not  an 
emergency,  or  if  the  emergency  is  so  moderate  that  it  has  been  decided 
to  do  the  operation  in  two  stages,  the  bowel  presenting  at  the  wound, 
whether  left  or  right,  may  be  opened  by  a  small  puncture  of  the  knife, 
or  burnt  through  with  the  Paquelin  cautery,  without  anesthetic,  any 
time  after  six  hours.  The  skin  round  the  wound  should  be  painted 
with  compound  tincture  of  benzoin  or  smeared  with  zinc  oxid  ointment, 
or  both.  A  small  pad  of  gauze  or  absorbent  cotton  will  do  for  a  dressing 
while  the  patient  is  still  in  bed.  When  the  patient  gets  up,  special  devices 
must  be  used  to  maintain  cleanliness. 

The  method  above  employed — namely,  sewing  the  gut  to  the  peri- 
toneum— is  far  from  being  the  best  practice  at  present.  The  use  of 
the  Paul  ^  or  the  Mixter  (identical  but  devised  independently)  tube  is 
much  to  be  preferred. 

The  glass  tubes  are  made  in  two  sizes.  That  used  for  the  colon  measures 
4l  inches  in  length  by  I  inch  in  diameter,  has  a  double  rim  at  the  bowel  end 
and  a  single  rim  at  the  distal  end,  and  is  bent  at  a 
right  angle.  The  tube  for  the  small  intestine  (Fig.  133) 
is  as  light  as  is  consistent  with  sufficient  strength. 
It  measures  3^  in.  by  ^  in.,  and  is  bent  at  a  right 
angle  at  the  distal  end.  In  either  case,  the  end  with 
the  double  rim  is  introduced  into  a  small  incision 
made  in  the  loop  of  the  intestine,  drawn  out,  if 
possible,  and  safely  cut  off  with  aseptic  gauze  pack- 

,  .  ,  f    1-  .1  J  -n    ;  Fig.  133.— Paul's  Tube. 

mg.     A  purse-strmg  suture  of  -Imen  thread  or  silk  is 

sewed  into  the  wall  of  the  gut.  An  incision  is  made  within  the  circle  of  the 
suture.  The  tube  is  then  inserted  and  secured  by  tying  the  purse-string. 
The  loop  bearing  the  tube  is  now  dropped  back  into  the  peritoneal  cavity. 
Feces  from  the  tube  are  received  through  a  rubber  tube,  and  conveyed  into 
a  bottle  hung  on  the  side  of  the  bed.  Two  objections  have  been  made  to 
^Brit.  Med.  Jour.,  1891,  ii,  118. 


422 


OPERATIONS    ON    THE    ABDOMEN 


the  use  of  these  tubes.  One,  that  it  is  difficult  to  insert  the  tube  without 
letting  the  feces  escape  over  the  wound.  This  is  certainly  true  when  the 
intestine  is  distended  and  the  feces  fluid.  If,  however,  the  loop  to  be  opened 
is  emptied  into  an  adjacent  bowel,  and  temporarily  clamped  if  possible,  the 
introduction  of  the  tube  is  greatly  simplified;  otherwise,  the  operator  may 
safely  trust  to  drawing  out  the  bowel  as  much  as  possible  and  isolating  it  with 
gauze.  The  other  objection  is  that  the  ligature  may  cut  its  way  through  too 
quickly,  "  especially  if  the  bowel  is  much  congested.  Thus  the  tube  may  be 
loose  in  two  or  three  days;  but  it  not  infrequently  remains  for  a  week  firmly 
adherent,  partly  because  some  of  the  circulation  becomes  reestablished  behind 
the  ligature,  and  partly  owing  to  the  copious  exudation  of  lymph,  which  covers 


Fig.  134. — Colostomy. 

The  Paul  or  Mixter  tube  has  been  tied  in  the  cecum,  with  rubber  drainage   tubing  previously  attached,  a 
hemostat  on  the  end  for  transit  from  operating-table  to  bed. 

the  bowel  to  the  very  end,  quite  conceaUng  the  ligature.  The  use  of  a  purse- 
string  suture  to  fix  the  tube  in  the  bowel,  and  the  prevention  of  undue  tight- 
ness in  tying  in  the  tube,  will  help  to  lessen  this  trouble."^ 


Such  a  tube  is  fastened  into  the  bo^^-el  by  a  purse-string  suture  of 
catgut,  and  drainage  leads  over  the  bedside  by  means  of  a  rubber  tubing 
attached  and  running  into  a  bottle.  The  Paul  tube  comes  out  with 
gentlest  traction  or  even  by  itself  at  the  end  of  five  or  six  days,  leaving 
a  well-formed  and  controllable  artificial  anus.  If  now  a  small  and  effi- 
cient device  be  applied,  such  as  that  effected  by  H.  B.  Jackson  (see  Fig. 
135,  p.  426),  this  opening  can  be  kept  under  good  control,  particularly 
if  the  muscles  have  been  opened  by  the  muscle-splitting  or  McBurney 
type  of  incision.  Another  method,  also  simple,  is  the  use  of  a  small 
pad,  conical  in  shape,  held  in  position  by  a  truss.     If  the  wound  is  low, 

^  Jacobson  and  Steward,  ii,  226. 


COLOSTOMY  423 

particularly  in  a  more  or  less  prominent  or  pendulous  abdomen,  a  well- 
fitted  spring  truss,  exerting  only  slight  pressure,  will  serve  well. 

If  the  opening  in  the  bowel  is  too  large,  the  mucosa  may  prolapse, 
exposing  a  moist,  excoriated,  bleeding,  cauliflower-like  mass  on  which 
it  is  difficult  to  keep  any  dressing.  If  the  opening  in  the  bowel  is  too 
small,  repeated  dilatation  by  the  finger  or  some  opener  of  the  glove- 
stretcher  type  may  be  necessary. 

Feces  beyond  the  colostomy,  whether  it  be  right  or  left  side,  may  be 
cleared  out  from  time  to  time  by  enemas  passed  through  a  small  catheter, 
provided  the  stricture  or  disease  for  which  the  operation  was  done  is  not 
absolute.  If  this  is  not  feasible,  into  the  distal  bowel  should  be  passed, 
through  the  colostomy,  either  a  thorough  rapid  salt-water  irrigation, 
or,  if  this  does  not  suffice  to  cleanse  the  gut,  any  one  of  the  approved 
irritative  enemas  (p.  148).  By  this  method  the  gut  may  be  efficiently 
cleaned  throughout. 

Complications  and  Sequelae. — Where  this  operation  has  been 
done  for  obstruction  due  to  malignant  disease,  death  may  follo^^'  despite 
treatment /row  exhaustion  and  toxemia — (i)  due  to  the  absorption  of  poi- 
sonous matter  through  the  obstruction  and  to  strain  of  operation,  par- 
ticularly if  there  has  been  much  pulling  on  the  gut;  (2)  due  to  peritonitis 
from  extravasation  of  feces  or  to  actual  suppuration.  "Often  it  is  not 
due  to  the  operation,  but  to  the  want  of  it  at  an  earlier  stage.  Thus, 
the  distended  bowel  may  have  given  way  just  above  the  obstruction; 
often  it  is  that  v/eak  spot,  the  cecum,  which  is  found  perforated  after 
the  stress  of  distention"^;  (3)  due  to  bronchopneumonia,  such  as  may 
be  looked  for  in  any  aged  patient  who  has  had  ether.  If  this  operation 
has  been  done  for  acute  peritonitis  (an  excellent  procedure),  and  if  all 
goes  well  at  the  end  of  ten  days,  the  patient  may  be  given  an  anesthetic 
in  bed  and  a  few  No.  i  chromic  catgut  sutures  taken  in  the  rent  in  the 
cecum.  If  the  patient's  condition  is  good,  there  is  no  advantage  in  wait- 
ing longer. 

Small  intestine  may  escape  between  the  drained  gut  and  the  edges 
of  the  wound  during  a  fit  of  coughing  or  straining.  This  must  be 
thoroughly  cleaned  and  returned,  best  under  an  anesthetic,  but  still  in 
bed.  When  omentum  protrudes,  it  should  be  left,  but  it  should  be 
fastened  to  the  skin  by  sutures  and  cut  off  in  two  or  three  days.  Bowel 
sewed  to  the  abdominal  wall  under  tension  may  tear  away  from  its  at- 
tachments and  begin  to  empty  itself  into  the  peritoneum.  This  calls 
for  immediate  and  thorough  operation.  The  small  intestine  may  strangu- 
late between  the  edge  of  the  colon  and  the  parietes.     This  may  happen 

'  Jacobson,  i,  loi. 


424  OPERATIONS    ON   THE   ABDOMEN 

at  any  time,  near  or  remote,  after  the  operation,  particularly  in  case  of 
a  median  enterostomy,  a  very  dangerous  procedure,  to  be  done  only 
under  greatest  urgency. 

A  doctor,  keen  observer  and  ingenious,  suffered  from  general  peri- 
tonitis for  which,  among  other  things,  cecostomy  was  done.  He  made  a 
good  recovery,  the  fecal  fistula  remaining  open,  however.  It  remained 
open  nearly  a  year,  largely  because  the  doctor  was  too  busy  to  take  the 
time  to  have  it  closed.  The  following  is  his  story  from  the  subjective 
point  of  view: 

"The  routine  care  of  a  colostomy  wound  presents  several  features 
not  generally  encountered  in  ordinary  open  wounds.  The  amount  of 
the  discharge  is  great,  particularly  repulsive,  and  is  likely  to  be  very 
irritating  to  the  skin,  either  from  putrefactive  products  or  from  free 
digestive  ferments.  Then,  too,  the  wound  is  likely  to  remain  open  so  long 
that  the  patient  frequently  assumes  the  upright  posture,  and  may  even, 
become  an  active  individual  before  the  hole  in  his  side  closes. 

"  It  is  then  essential  that,  immediately  after  a  colostomy  has  been  per- 
formed, particularly  if  it  is  located  high  in  the  colon,  or  the  contents  of 
the  bowel  are  putrefying,  or  in  any  way  seem  likely  to  become  the  source 
of  irritation,  an  effort  must  be  made  to  protect  the  skin.  Accordingly,  until 
the  dermal  resistance  has  been  determined,  the  dressing  must  be  changed 
w^henever  soiled,  even  if  it  be  as  often  as  once  an  hour.  Of  the  remedies 
generally  used  to  prevent  irritation  of  the  skin,  tinctura  benzoinatus  com- 
positus  is  probably  the  best.  i\.t  the  first  dressing  it  should  be  painted 
on  over  a  generous  area  about  the  wound  with  a  camel's-hair  brush, 
the  skin  having  been  previously  cleansed  with  alcohol  and  dried.  One 
coat  dries  quickly  and  is  nearly  as  effective  as  two,  but  if  the  second  is 
applied,  it  must  be  dried  ten  to  fifteen  minutes  before  the  dressing  is 
applied,  else  the  latter  will  stick  to  the  benzoin  and  the  additional  pro- 
tection will  be  nullified.  A  coating  of  benzoin  will  often  last  a  number 
of  hours,  frequently  as  many  as  twelve,  but  it  should  be  renewed  when- 
ever it  begins  to  come  off.  If  the  skin  is  unirritated  or  unbroken,  the 
application  of  the  benzoin  is  painless,  but  if  either  condition  prevail, 
or  any  of  the  benzoin  enters  the  wound,  an  intense  burning  sensation, 
lasting  fortunately  but  a  minute  or  two,  immediately  supervenes.  This 
disagreeable  feature,  however,  can  be  shortened  to  a  few  seconds  by 
briskly  fanning  the  field  as  soon  as  the  application  is  made.  If  these 
t^vo  precautions  are  carefully  observed,  there  should  be  little  difficulty 
in  keeping  the  skin  from  becoming  irritated.  If,  however,  for  any  reason 
it  becomes  so  sore  that  it  is  deemed  best  not  to  apply  the  benzoin,  a  free 
use  of  zinc  oxid  ointment,  or,  better  still,  an  ointment  such  as  the  fol- 


COLOSTOMY 


425 


lowing,  together  with  extreme  caution  in  quickly  removing  the  discharge, 
will  soon  relieve  this  distressing  condition: 

"  I^.     Zinci  oxidi 3i 

Bismuthi  subnit 3ij 

Amyli 3iv 

Ung.  aquae  rosae ^ §ij. 

"  Often  allowing  the  skin  to  be  exposed  to  the  air  while  covered  with 
ointment  seems  materially  to  assist  in  quieting  irritation. 

"  When  the  intestinal  contents  are  normal,  the  skin  will  generally 
maintain  its  integrity  with  only  a  little  ointment  smeared  on  at  the  time 
of  dressing,  but  it  should  be  borne  in  mind  that  with  any  tendency  to 
diarrhea,  intestinal  putrefaction,  or  if  cathartics  are  used,  the  skin 
breaks  down  (probably  in  the  latter  case  from  digestive  action)  with 
marvelous  rapidity.  I  recall  a  case  of  cecostomy  which  had  been  get- 
ting on  well  for  a  long  time  where  the  skin  became  nearly  raw  within 
three  hours  of  taking  a  dose  of  castor  oil.  It  might  be  proper,  how- 
ever, to  add  that  in  this  case  the  intestines  contained  little  or  no  food,  so 
that  it  was  pure  intestinal  secretion  that  was  poured  out. 

"  The  problem  of  the  control  of  the  discharge  is  often  somewhat 
difficult.  Within  a  few  moments  enough  material  may  be  poured  out  in 
successive  gushes  to  soak  through  or  escape  from  under  a  large  dressing, 
to  the  great  annoyance  of  the  patient.  While  he  is  in  bed,  the  annoy- 
ance is  comparatively  slight,  as  he  may  be  surrounded  by  such  dress- 
ings and  clothing  as  can  be  easily  removed,  but  when  he  assumes  an 
upright  posture,  it  will  be  found  well-nigh  impossible,  even  with  an  elastic 
belt,  to  hold  a  dressing  to  the  side  firmly  enough  to  keep  the  intestinal 
contents,  if  it  be  at  all  liquid,  from  running  down  betw^een  the  skin  and 
dressing  before  it  is  absorbed  by  the  latter.  Furthermore,  if  the  dress- 
ing is  held  firmly  against  the  abdominal  wall  with  nothing  but  a  swathe 
or  elastic  belt,  it  will  slip  and  pull  sufficiently  with  respiration  and 
the  various  movements  of  the  body  to  irritate  the  edges  of  the  wound, 
perhaps  already  more  or  less  inflamed  and  eroded  by  the  discharge. 
Both  of  these  difficulties  may  be  overcome  in  a  large  measure  by  the 
following  device: 

"  Take  three  pieces  of  zinc  oxid  adhesive  plaster,  2  to  3  in.  in  width  and 
about  3  in.  long,  and  sew  on  the  back  two  heavy  dressmakers'  hooks, 
about  J  in.  from  one  end  of  each  strip.  Place  these  strips,  a,  b,  c  (see 
Fig.  135),  radially  about  the  wound,  so  that  a  shall  be  directly  below 

^  A  better  preparation  is  made  by  substituting  white  petroleum  oil  for  the  almond  oil 
called  for  by  the  U.  S.  P. 


426 


OPERATIONS    ON    THE    ABDOMEN 


and  the  hook  ends  of  each  plaster  shall  be  about  i^  to  2  in.  from  the 
opening.  As  any  discharge  that  reaches  the  plasters  soils  them  and 
tends  to  work  them  loose,  it  is  well  to  stick  on  a  guard  strip  of  plaster, 
X,  I  to  f  in.  wide,  and  lapping  onto  the  ends  of  the  plasters  a,  b,  c. 

"  These  may  be  removed  frequently  without  disturbing  the  main  plas- 
ters, and  thereby  saves  considerable  time  to  the  attendant  and  discom- 
fort to  the  patient.  If,  when  the  main  plasters  are  removed,  they  are 
first  moistened  with  ether,  they  will  come  off  without  pulling  and  con- 
sequently without  pain  or  injury  to  the  epidermis. 

"The  plasters  having  been  placed,  a  dressing  can  be  put  on  over 
the  wound,  filling  the  space  between  the  hooks,  and  a  lacing  passed  from 
the  hooks  on  plaster  a  to  each  of  the  hooks  on  plasters  h  and  c.  This 
will  serve  a  triple  purpose — to  hold  the  dressing  next  the  wound  without 


Fig.   135. — Diagram  to  Show  Arrangement  of  Adhesive  Plaster  Strips  Used   in  Maintaining  a 
Dressing  in  Ambulatory  Colostomy  Cases. 

a,  h,  c.  Squares  of  plaster  to  which  are  sewn  dressmakers'  hooks,     x,  x,  x,  guard  strips  to  prevent  moisture 

working  under  main  plasters. 

slipping,  and  sufficiently  firmly  along  its  lower  border  to  check  the  dis- 
charge from  running  down  rapidly,  and  so  escaping  absorption  from  the 
large  dressing  of  absorbent  cotton  placed  over  and  below  the  dressing  just 
described,  and  which  is  held  in  place  by  a  swathe,  with  or  without  an 
elastic  belt.  Finally,  in  case  there  is  no  obstruction  of  the  bowel,  and 
it  is  desired  that  the  wound  should  close,  this  form  of  dressing  is  par- 
ticularly advantageous,  inasmuch  as  it  draws  the  edges  of  the  wound 
together,  thereby  assisting  in  the  healing.  In  such  case,  if  the  in- 
testinal contents  are  normal,  the  plasters  should  be  brought  nearer 
the  wound  and  as  much  pressure  placed  over  the  opening  as  the  tissues 
will  bear.  Four  strips  of  plaster  instead  of  three,  placed  opposite  each 
other,  will  be  found  more  effective  for  this  purpose. 

"  As  to  the  care  of  the  wound  itself,  little  is  required  that  is  not 


INTESTINAL   END-TO-END    ANASTOMOSIS  427 

required  by  other  open  abdominal  wounds.  After  the  tube  has  been  re- 
moved or  has  come  away,  a  sterile  dressing  should  be  used  for  a  few^  days, 
after  which  plain  gauze  and  absorbent  cotton  are  all  that  are  needed. 
Granulations  may  require  trimming  down  either  with  scissors  or  caustic. 
If,  when  the  wound  has  closed  down  to  a  fistula,  it  is  packed  at  each 
dressing  with  the  ointment  previously  mentioned  (which  at  body  tem- 
perature remains  firmer  than  most  ointments  with  a  petroleum  base), 
the  edges  are  less  likely  to  become  sore,  and  the  discharge  does  not  seem 
to  make  its  escape  as  readily  as  when  no  ointment  is  used.  This  latter 
statement,  of  course,  has  reference  only  to  those  cases  where  there  is  no 
obstruction. 

"■  From  what  has  been  said  about  loose  and  irritating  discharges  it 
will  be  evident  that  the  diet  must  be  so  arranged  as  to  be  easily  digested, 
and  a  moderate  degree  of  costiveness  will  give  rise  to  less,  local  disturb- 
ance than  will  the  opposite  condition  of  the  bowels. 

"  In  conclusion  it  may  be  said  that  the  successful  treatment  of  a 
cecostomy  wound  requires  much  patience  on  the  part  of  the  physician 
and  patient,  and  constant  intelligent  attention  on  the  part  of  the  attend- 
ant. Given  these,  the  patient,  so  far  as  the  wound  itself  is  concerned, 
may  be  kept  tolerably  comfortable  and  may  even  lead  a  moderately 
active  life." 

.     JEJUNOSTOMY 

This  is  a  very  rare  operation,  and  has  the  disadvantage  of  causing 
leakage  high  in  the  alimentary  tract,  with  escape  of  digestive  fluids 
of  the  greatest  importance  to  nutrition.  It  has  been  done  for  cancer 
of  the  stomach  where  other  operations  are  impossible. \ 

The  operation  is  performed  in  two  stages:  after  the  gut  has  become 
firmly  adherent  to  the  abdominal  wound  it  is  opened,  three  or  four 
days  after  the  first  operation,  and  the  patient  is  fed  by  funnel  into  this 
opening.  The  feeding  is  done  by  giving  a  meal  of  about  lo  ounces 
every  four  hours,  half  of  it  being  directed  upward  toward  the  duodenum, 
the  other  half  downward  toward  the  ileum. 

INTESTINAL   END-TO-END   ANASTOMOSIS,    OR  CIRCULAR  ENTEROR- 

RHAPHY 

The  tendency  in  this  operation  is  constantly  toward  less  apparatus 
and  more  simplicity.  The  choice  of  operation  at  the  present  day  lies, 
perhaps,  between  Connell's  method-  of -direct  suture,  Murphy's  button,^ 

^  E.  Hahn,  Deut.  mcd.  Woch.,  1894,  xx,  557. 
^  Jour.  Amer.  Med.  Assoc,  1901,  xxxvii,  952. 
^New  York  Med.  Record,  Dec.  10,  1892. 


428  OPERATIONS    ON    THE    ABDOMEN 

and  Mayo-Robson's  ^  bobbin  of  decalcified  bone,  with  every  advantage 
in  favor  of  the  first  if  time  permits. 

Enterorrhaphy  by  circular  suturing  must  be  admitted  to  be  the 
ideal  operation  from  its  simplicity,  the  entire  absence  of  any  special 
apparatus,  and  the  fact  that  no  foreign  body  is  left  behind  to  give 
trouble.  Comparison  between  Murphy's  button  and  other  methods  of 
resection  in  the  series  of  226  cases  of  resection  of  intestine  for  gan- 
grenous hernia,  collected  by  Gibson,-  is,  on  the  whole,  to  the  advantage 
of  Murphy's  button;  for  in  the  63  cases  in  which  INIurphy's  button  was 
used,  there  were  14  deaths,  or  22  per  cent.,  \a  hile  in  the  remaining 
163  cases,  in  which  various  other  methods  were  used,  there  were  44 
deaths,  or  27  per  cent. 

The  after-treatment  varies  little  from  that  of  gastro-enterostomy 
(p.  411).  A  wick  is  left  going  down  to  the  site  of  the  intestinal  wound. 
This  is  removed  on  the  third  day.  Water  is  given  from  the  first. 
Rectal  feeding  is  begun  at  the  end  of  the  first  tAventy-four  hours  and 
continued  to  the  end  of  sixty  hours  at  least.  If  there  are  then  no 
signs  of  general  or  local  infection  of  the  peritoneum,  liquid  diet,  |  to 
2  ounces  every  tAvo  hours  by  day,  are  begun  and  rapidly  increased  in 
amount  if  no  complications  arise.  While  the  rectal  feeding  is  main- 
tained, the  bo\yel  should  be  cleansed  daily  (p.  122);  when  feeding  by 
mouth  is  resumed,  the  bowels  should  be  moved  by  enemas  only  till  the 
fourteenth  day. 

Complications  and  Sequelae. — (i)  Sepsis  or  gangrene  at  point 
oj  union  may  show  itself  either  in  a  general  peritonitis  or  as  a  localized 
abscess  at  the  site  of  the  intestinal  operation,  with  possibly  a  fecal 
fistula  (pp.  246  and  424). 

(2)  The  Button  May  Not  Pass. — If  no  symptoms  arise,  this  need  not 
disturb  doctor  or  patient.  The  button  may  make  difficulty  in  passing 
the  external  sphincter;  it  may  cause  obstruction  in  the  gut  and  call 
for  intervention.     It  should  come  away  by  the  fourteenth  day. 

ABSCESS  OF  LIVER 

After  the  abscess-caA'ity  has  been  thoroughly  opened,  a  large  gauze 
wdck  is  packed  into  it,  other  wicks  draining  the  fossa  below  the  liver 
and  walling  off  the  general  peritoneal  cavity.  The  wound  is  covered 
with  a  large  sterile  gauze  dressing  and  the  patient  kept  on  the  right 
side  in  bed  to  encourage  free  drainage.  The  outer  layer  of  gauze  is 
reinforced  whenever  it  becomes  necessary.     The  wicks  are  removed 

^  Brit.  Med.  Jour.,  1896,  i,  451. 

^  C.  P.  Gibson,  Ann.  Surg.,   1900,  xxxii,  4S6,  676. 


HYDATID    CYST    OF    THE    LIVER  429 

on  the  fourth  day  and  replaced,  being  changed  daily  thereafter,  and 
shortened  at  each  dressing.  They  are  left  out  when  the  discharge  from 
the  wound  ceases  to  be  purulent  and  the  sinus  has  closed  to  a  depth  of 
3  in.  When  there  is  a  discharge  of  bile,  the  edges  of  the  wound  must  be 
kept  smeared  with  some  protective  salve,  such  as  stearate  of  zinc  oint- 
ment.    The  stitches,  if  any,  are  removed  on  the  tenth  day. 

The  general  principles  of  after-treatment  to  be  followed  do  not  vary 
in  the  main  from  those  in  any  celiotomy.  These  patients  are  always 
extremely  sick,  and  stimulation  forms  an  important  part  of  the  after-care. 
When  recovery  takes  place,  the  stay  in  bed  will  depend  largely  upon  the 
patient's  condition,  seldom  being  less  than  four  weeks.  The  patient 
should  be  kept  in  bed  until  the  temperature  has  been  normal  at  least 
a  week  and  until  the  sinus  has  well  closed  down. 

Complications  and  Sequelae. — Septicopyemia  is  extremely  com- 
mon and  usually  fatal.  Peritonitis  or  empyema  and  septic  pneumonia 
may  have  developed  before  operation  from  rupture  of  the  abscess  either 
into  the  peritoneal  cavity  or  through  the  diaphragm.  The  treatment 
of  these  complications  is  described  in  the  appropriate  sections. 

Secondary  hemorrhage  may  occur  and  necessitates  repacking  the 
wound  in  the  liver  with  a  firm  gauze  pack.  Failure  to  open  up  all  the 
abscess-cavities  in  the  liver  is  probably  the  most  common  complication 
and  the  most  frequent  cause  of  death  after  this  operation.  This  is 
usually  unavoidable.  All  that  can  be  done  at  the  time  of  operation  is  to  - 
explore  the  abscess-cavity  as  thoroughly  as  possible  and  try  to  open  all 
pockets.  If  after  operation  there  is  still  elevation  of  temperature  which 
shows  no  downward  tendency,  it  is  at  least  worth  while  thoroughly  to 
explore  the  sinus  again  and  endeavor  to  find  an  unopened  abscess. 

A  biliary  fistula  frequently  develops,  but  spontaneous  closure  is  the 

rule. 

HYDATID  CYST  OF  THE  LIVER 

The  operation  for  this  condition  may  be  done  in  one  or  two  stages. 
If  the  latter,  the  liver  over  the  tumor  is  sewed  to  the  abdominal  wound, 
and  the  tumor  is  then,  or  three  days  later,  incised  and  drained.  Hemor- 
rhage from  the  cyst  wall,  at  the  first  moment  of  relief  of  tension,  is  met 
.  by  packing.  The  cavity  will  have  to  be  packed  firmly  and  may  take 
many  months  to  heal.  It  may  .well  be  wiped  out  every  two  or  three  days 
with  full  strength  tincture  of  iodin. 

If  the  operation  is  conipleted  at  one  sitting,  the  cyst  is  opened  and 

drained  and  its  lining  removed  so  far  as  possible.     The  cavity  is  packed 

with  sterile  gauze,  and  another  gauze  wick  is  passed  into  the  abdomen 

.  below  the  liver  to  wall  off  this  region.     These  wicks  are  both  removed 


430 


OPERATIONS    ON    THE    ABDOMEN 


on  the  fourth  day  and  replaced  by  a  single  wick  into  the  cyst  cavity. 
The  dressing  is  then  done  daily,  the  gauze  drain  being  shortened  each 
time.  When  discharge  from  the  sinus  is  reduced  to  a  minimum,  and  its 
depth  does  not  exceed  3  in.,  drainage  is  omitted.  Stitches  are  removed 
on  the  tenth  day. 

The  general  principles  of  after-treatment  are  the  same  as  after  any 
celiotomy.  The  length  of  stay  in  bed  will  depend  upon  the  rapidity 
with  which  the  wound  closes — usually  about  three  weeks. 

Complications  and  Sequelae. — Infection  is  to  be  met  by  free 
drainage.  Secondary  hemorrhage  is  to  be  controlled  by  packing  the  liver 
wound  firmly  with  gauze. 

Biliary  fistulae  close  spontaneously,  and  require  only  that  the  skin 
about  the  wound  be  kept  in  good  condition  by  smearing  it  t^vice  or  three 
times  a  day  with  10  per  cent,  stearate  of  zinc  ointment. 


GALL-BLADDER  AND  BILIARY  PASSAGES 

Bevan's  incision  (Fig.  136)^  is,  in  my  experience,  by  all  odds  the  "best, 
the  most  favorable  for  exploration  and  drainage,  and  most  efficient  for 
after-care.     This  is  the  so-called  S-incision,  a  main  vertical  arm  with  an 

extension  at  the  upper  end  inward  and  at  the 
lower  end  out\vard  if  necessary.  Preliminary 
to  the  after-treatment  of  gall-bladder  opera- 
tions, it  should  be  noted  that  undoubtedly 
surgeons  drain  gall-bladders  which  had  better 
be  removed,  and  it  is- here  appropriate,  there- 
fore, to  insert  remarks  on  the  place  of  chole- 
cystectomy. 

Dr.  Maurice  H.  Richardson^  gives  the  fol- 
lowing indications  for  extirpation  of  the  gall- 
bladder : 


Fig.  136. — Sevan's  Incision 
FOR  Operations  on  Gall-bl.-vd- 
DER  AND  Bile-ducts  (Keen's 
Surgery). 


' '  (i)  Certain  lesions  in  themselves  demand  re- 
moval of  the  gall-bladder  whenever  possible.  Such 
are  new-growths  and  gangrenes.  (2)  Certain  other 
lesions  of  the  gall-bladder  are  better  treated  by  cholecystectomy.  These 
are  the  contracted  and  inflamed  gall-bladders  with  thickened  walls.  All 
gall-bladders  which  do  not  permit  easy  and  efficient  drainage  should  be  ex- 
tirpated, for  in  such  gall-bladders  the  risks  of  drainage  are  quite  as  great 
as  the  risks  of  extirpation,  and  the  one  great  advantage  of  retention  is  im- 
possible— retention  of   the  biliary  reservoir  to  fulfil  the  functions  of  that 

^  Ann.  Surg.,  1S99,  xxx,  17. 

^  Med.  News,  New  York,  1903,  Ixxxii,  S17. 


CHOLECYSTOTOMY  43 1 

reservoir,  and  to  permit,  if  necessary,  renewed  drainage  in  future  years. 
(3)  Drainage  is  preferable  in  the  dilated  and  infected  gall-bladder,  which, 
however,  is  neither  gangrenous  nor  to  any  great  extent  changed — the  slightly 
thickened  gall-bladder  containing  gall-stones  and  infected  bile.  This  gall- 
bladder will,  after  drainage,  become  normal,  and,  therefore,  capable  of  ful- 
filling the  functions  of  a  gall-bladder.  Through  it  the  biliary  passages  will 
become  effectually  drained,  after  subsidence  of  the  temporary  swelling  about 
the  cystic  duct.  (4)  As  a  rule,  drainage  rather  than  extirpation  is  demanded 
in  acute  cholecystitis  with  severe  constitutional  symptoms,  when  the  gall- 
bladder is  dilated,  or  at  least  not  contracted,  and  when  it  is  not  gangrenous. 
(5)  In  chronic  cholecystitis,  with  dilatation  and  thickening  of  the  gall-bladder, 
especially  when  a  stone  is  impacted  in  the  cystic  duct,  extirpation  is  the  pref- 
erable operation,  unless  the  stone  can  be  dislodged  backward  into  the  gall- 
bladder, in  which  case  drainage  is,  if  not  preferable,  quite  as  advantageous  as 
extirpation.  (6)  In  simple  gall-stones,  without  visible  evidence  of  infection 
or  chronic  changes  incompatible  with  restoration  of  function,  simple  drainage 
of  the  gall-bladder  is  indicated.  (7)  In  chronic  pancreatitis,  whether  associated 
with  gall-stones  or  not,  drainage  through  the  gall-bladder  is  indicated.  Cho- 
lecystectomy is  unjustifiable,  for  immediate  drainage  is  essential.  Further- 
more, reopening  of  the  biliary  passages  may,  in  the  future,  be  required." 

The  after-care  of  cholecystectomy  is  similar  to  that  for  cholecystot- 
omy,  which  follows. 

CHOLECYSTOTOMY 

A  piece  of  rubber  tubing,  in  diameter  ^  to  ^  in.,  with  fairly  stiff  walls, 
rounded  at  the  end,  with  one  or  two  windows  cut  near  the  proximal 
end,  is  inserted  into  the  wound  of  the  gall-bladder.  It  is  long  enough 
to  reach  to  the  deepest  part  of  the  gall-bladder.  It  is  held  in  by  a  purse- 
string  suture  of  catgut,  placed  far  enough  from  the  edge  of  the  gall- 
bladder wound  to  allow  invagination  of  the  gall-bladder  wall  round 
the  tube.  This  invagination  is  done  in  order  that  after  removal  of 
the  tube  in  due  time  the  invaginated  serous  surfaces  will  approximate 
and  heal.  This  procedure  is  supposed  to  shorten  to  a  notable  degree 
the  duration  of  the  biliary  fistula.  Deep  in  the  flank,  or  in  any  other 
region  where  bile  or  other  possibly  infective  matter  has  reached  during 
the  operation,  a  wick  or  some  other  form  of  drain  is  placed.  The  skin 
wound  is  entirely  closed  except  for  these  wicks  and  for  the  gall-bladder 
drainage-tube.  The  tube  is  now  insured  against  pulling  out  by  motions 
of  the  patient  by  fastening  it  to  the  skin,  as  it  emerges,  with  a  single 
stitch. 

A  voluminous  dressing  is  applied,  and  the  swathe  is  so  pinned  that 
the  tube  emerges  between  t^^•o  safety-pins  where  the  ends  of  the  swathe 


432  OPERATIONS   ON   THE   ABDOMEN 

proximate.  A  hemostatic  forceps  is  snapped  on  the  end  of  the  drainage- 
tube  until  the  patient  reaches  the  bed.  The  drainage-tube  is  then  con- 
nected by  a  glass  tube  to  a  long  rubber  tube  hanging  over  the  edge  of 
the  bed  into  a  bottle  fastened  to  the  bed-frame.  Siphon  drainage  is 
then  estabhshed. 

The  dressing  is  changed  as  often  as  it  is  stained.  The  tube  is  left  in 
the  gall-bladder  for  a  period  varying  from  three  days  to  two  weeks, 
depending  on  the  amount  of  cholecystitis  originally  present  and  per- 
sisting. Whenever,  after  the  third  day,  the  temperature  becomes  normal, 
the  drainage-tube  is  removed.  The  dressings  then  have  to  be  changed 
with  great  frequency  at  first.  The  skin  is  preserved  against  maceration 
and  irritation  by  the  application  of  compound  tincture  of  benzoin,  sterile 
zinc  ointment,  or  some  such  emollient.  The  fistula  will  remain  open 
for  a  period  varying  from  ten  days  to  many  weeks  and  even  months. 
They  always  eventually  close  if  the  common  duct  is  patent  and  if  no 
malignant  disease  is  present.  The  patency  of  the  common  duct  is  to 
be  proved  by  investigation  at  the  time  of  operation,  and  by  the  presence 
of  bile  in  the  stools. 

The  patient  has  five  pillows  on  the  second  and  third  day  and  may  get 
up  in  seven  to  ten  days.  These  patients  are  so  often  fat  and  very  thick- 
walled  that  one  should  be  relatively  conservative  in  getting  them  up. 
Too  much  emphasis  has  been  put  upon  the  statement  that  ventral 
hernia  is  relatively  rare  in  the  upper  quadrants.  Some  of  the  worst 
hernia  seen  are  through  gall-bladder  incisions.  The  stitches  should 
come  out  on  the  tenth  to  twelfth  day.  The  bowel  should  be  moved 
from  the  first  with  calomel  and  the  alkaline  salts.  If  after  such  mild 
purging  for  a  week  or  ten  days  no  bile  appears  in  the  stools,  it  may  be 
assumed  that  the  common  duct  remains  or  has  become  blocked,  and 
ultimately  further  operation  may  be  necessary. 

If  the  patient  walks,  a  fitted  belt  may  be  desirable  to  hold  on  the  bile- 
stained  dressing.  Toward  the  end  of  the  drainage  the  discharge  will 
appear  in  spurts,  much  one  day  and  then  none  perhaps  for  two  or  three 
days,  then  drainage  again,  etc. 

Anemia  should  be  treated;  fats  and  milk  should  be  diminished  or 
absent  in  the  early  diet. 

Complications  and  Sequelse. — (i)  Hemorrhage,  delayed  or 
secondary,  is  not  infrequent  in  jaundiced  cases  and  in  cancer  of  the  gall- 
bladder, 

(2)  Peritonitis  may  result  from  escape  of  infected  bile  during  opera- 
tion, 

(3)  A  stone  not  found  during  operation  may  get  loose  from  deep  in 


CHOLECYSTEXTEROSTOMY  433 

the  gall-bladder  and  block  the  drainage-tube  or  the  common  duct,  and 
symptoms  of  obstruction  may  reappear. 

(4)  Persistence  of  jaundice  and  clay-colored  stools  mean  common- 
duct  obstruction  due  to  duodenitis,  choledochitis,  impacted  stone,  or 
cancer. 

CHOLECYSTENTEROSTOMY 

With  the  improved  technique  by  which  the  common  duct  can  be 
reached  to  remove  obstructions  in  any  part  of  it  the  operation  of  con- 
necting the  gall-bladder  and  the  intestine  is  now  rarely  necessary. 
Performed  with  either  a  Murphy  button  or  by  direct  suture,  it  calls  for 
no  special  after-treatment.  A  temporary  drain  goes  down  to  the  site  of 
operation,  to  be  removed,  if  there  is  no  leak,  within  two  or  three  days. 

Complications  and  Sequelae. — (i)  The  possibility  exists  of 
infection  of  the  ducts  and  the  liver  from  the  intestine.  The  chance  of 
this  may  last  a  long  time.  This  has  been  proved  in  one  case,^  where 
death  occurred  fifty-three  days  after  the  operation,  and  was  found  to  be 
due  to  infection  of  the  biliary  passages  in  the  liver,  exhibiting  numerous 
abscesses.  The  escape  of  intestinal  contents  into  the  gall-bladder  can 
with  certainty  be  prevented  only  by  short-circuiting  the  intestinal  con- 
tents by  an  entero-anastomosis. 

(2)  Contraction  of  the  opening  may  take  place  whatever  method  is 
used,  unless  the  opening  is  made  very  large. 

(3)  Hemorrhage  from  the  wall  of  the  gall-bladder  is  distinctly  pos- 
sible, especially  if  malignant  disease  is  present.  If  packing  fails  to 
stop  such  a  hemorrhage,  the  actual  cautery  should  be  tried.^ 

^  Rickard,  Bull.  Soc.  Chir.,  1894,  xx,  592,  quoted  by  Jacobson. 

^  Shephard  (Ann.  Surg.,  1893,  581)  reports  a  patient  aged  thirty-six,  who  had  a  bil- 
iary fistula  resulting  from  a  previous  cholecystotomy  for  jaundice,  pain,  etc.,  performed 
four  months  previously,  vs^hen  no  stone  was  found.  Owing  to  the  annoyance  of  the  con- 
tinual discharge  of  bile,  the  abdomen  was  opened  again  by  an  incision  internal  to  the  old 
fistula  and  a  mass  of  malignant  disease  was  now  found  involving  the  pancreas  and  duo- 
denum. It  was  decided  to  unite  the  gall-bladder  ^^•ith  the  colon  instead  of  the  duodenum 
''as  being  easier  and  more  rapid,  and  quite  as  beneficial."  The  button  was  introduced 
without  very  much  difficulty,  a  purse-string  suture  being  first  inserted.  Owing  to  the 
thickness  of  the  gall-bladder  there  was  some  puckering,  and  the  parts  did  not  come  to- 
gether without  considerable  pressure  on  the  button.  On  dropping  back  the  bowel  and 
gall-bladder  with  the  button  there  was  no  contraction,  and  the  parts  seemed  to  be  in  accurate 
aipposition  and  to  he  comfortably.  It  was  decided  not  to  close  the  fistulous  opening,  as  it 
was  felt  that  this  would  close  of  itself.  On  the  morning  of  the  fourth  day  (the  patient 
ha\ang  gone  on  well  in  the  interval)  blood  was  found  to  be  oozing  from  the  gall-bladder  and 
the  abdomiiial  wound.  In  spite  of  gauze  packing  this  continued  and  the  patient  passed  into 
a  state  of  collapse.  On  opening  the  abdominal  wound  it  was  found  that  the  hemorrhage 
came  entirely  from  the  gall-bladder.  The  button  had  cut  through  the  thick  and  friable 
walls  and  could  be  easily  seen.  To  remove  the  button  it  was  necessary  to  incise  both 
gall-bladder  and  bowel  and  unscrew  the  button.     It  being  useless  to  reinsert  the  button, 

28 


434  OPERATIONS    ON   THE   ABDOMEN 

(4)  The  Button  May  Not  Be  Passed. — In  such  a  case  it  probably 
falls  back  into  the  gall-bladder  and  may  there  cause  no  inconvenience. 

CHOLECYSTGASTROSTOMY 

"No  special  directions  are  necessary  for  this  rare  operation.  The 
bile  is  in  no  way  injurious  to  the  stomach,  nor  does  it  interfere  with 
digestion."  ^ 

CHOLEDOCHOTOMY 

After  this  operation  the  surgeon  may  either  close  the  duct  by  suture 
or  may  drain  the  duct  by  rubber  tube.  On  the  whole,  at  the  present 
date,  drainage  is  the  usual  course.  This  drainage  may  be  direct  or 
indirect:  direct,  if  a  small  soft-rubber  tube  is  put  through  the  wound 
in  the  common  duct,  entering  the  duct  and  bending  upward  toward  the 
liver,  held  in  place  by  a  single  fine  catgut  suture.  The  tube  passes  up- 
ward toward  the  hepatic  duct  about  an  inch.  If  the  opening  in  the 
common  duct  is  large,  it  may  be  made  smaller  by  a  stitch  or  two  to  fit 
fairly  well  the  drainage-tube. 

''The  tube  is  stitched  in  by  a  single  catgut  suture  which  picks  up  the 
wall  of  the  common  duct  a  little  outside  the  edge  and  passes  through  the  tube. 
So  long  as  this  stitch  holds, — seven  to  ten  days, — the  tube  will  remain  in  place. 
In  addition  to  this,  tube  another  drain  is  necessary  on  the  outer  side  of  the 
duct.  For  this  I  prefer  a  rubber  tube  split  longitudinally,  wdth  a  fine  gauze 
wick.  The  tube  lies  to  the  outer  side  of  the  duct  in  the  kidney  pouch;  it  may 
be  brought  out  of  the  abdomen  incision  or  made  to  present  in  a  stab  wound 
of  the  loin — preferably  the  former.  A  third  tube,  to  lie  to  the  inner  side  of  the 
duct,  is  occasionally  necessary.  The  gauze  wick  projects  about  2  inches 
from  the  inner  end  of  these  tubes.  These  tubes  are  left  in  from  three  to  ten 
days,  as  seems  necessary.  There  is  no  advantage  in  removing  them  early. '  *■ 
(Moynihan,  Gall-stones,  1904,  p.  342.) 

Drainage  is  indirect  when  the  wound  in  the  common  duct  is  closed,, 
and  the  drain  is  left  either  in  the  gall-bladder  or  in  the  stump  of  the 
cystic  duct  if  the  gall-bladder  has  been  removed.  I  think  it  is  conceded 
that  the  best  surgeons  agree  that  suture  of  the  common  duct  is  ''always 
unnecessary  and  sometimes  harmful." 

"If  it  is  deemed  prudent,  the  common  duct  may  be  closed  by  suture. 
This  is  done  by  a  continuous  stitch  from  end  to  end  of  the  incision  in  two- 
it  was  decided  to  sew  up  the  openings  in  the  gall-bladder  and  colon.  A  fresh  oozing  took 
place  about  twenty-four  hours  later,  and  the  patient  sank.  A  partial  necropsy  showed 
that  the  obstruction  of  the  common  duct  was  due  to  malignant  disease  of  ribs  and  pan- 
creas.  ^  Moynihan,  Brit.  Med.  Jour.,  1901,  i,  1136. 


HEPATICODOCHOTOMY  435 

layers.  It  is  important  to  avoid  wounding  or  penetrating  the  mucosa,  as  any 
suture  which  gains  access  to  the  lumen  of  the  duct  may  formx  the  nucleus  of  a 
calculus.  When  the  wound  is  securely  closed,  a  split  rubber  tube,  with  a  gauze 
wick,  may  be  passed  down  to  the  duct  as  a  matter  of  precaution  in  the  unlikely 
event  of  any  leakage  ensuing."     (Moynihan,  loc.  cit.,  343.) 

CHOLEDOCHOSTOMY 

"This  operation  is  done  intentionally  for  enormous  cyst-like  dilata- 
tions of  the  common  duct,  the  opening  m  the  cyst  being  sewed  to  the 
peritoneum."  ^ 

CHOLEDOCHENTEROSTOMY;  CHOLEDOCHECTOMY 

These  operations  also  call  only  for  a  carefully  placed  wick  in  relation 
to  the  line  of  sutures  as  a  temporary  safeguard. 

CHOLEDOCHODUODENOSTOMY 

This  operation  2  calls  for  no  special  directions  in  after-care.  The 
temporary  preventive  drainage  is  placed  down  to  the  site  of  operation 
as  a  matter  of  safety. 

"One  point  cannot  be  too  frequently  nor  too  strenuously  emphasized; 
that  is,  that  drainage  is  the  secret  of  success  in  gall-bladder  surgery;  it  is  always 
an  advantage,  often  imperative.  In  cases  of  cholangitis,  as  made  manifest 
by  fever  or  jaundice,  or  both,  and  of  pancreatitis,  drainage  must  be  practised 
and  should  be  maintained  for  a  considerable  time."     (Moynihan,  p.  354.) 

DUODENOCHOLEDOCHOTOMY 

In  this  operation,  first  done  by  McBurney  in  1891,  the  duodenum 
is  opened  and  the  termination  of  the  common  duct  in  the  second  portion 
of  the  duodenum  exposed.  i\fter  the  stone  is  removed  the  split  ampulla 
is  not  sewed.  It  is  rather  an  advantage  to  leave  it  open.  If  the  stone, 
however,  lay  in  the  second  portion  of  the  duct,  the  opened  duct  will  have 
to  be  fastened  again  to  the  duodenum.  The  duodenum  is  then  closed, 
and  a  spiral  drain  is  put  down  to  the  line  of  suture. 

HEPATICODOCHOTOMY 

This  operation  needs  only  to  be  mentioned  and  reference  made  to 
a  single  characteristic  case.^ 

^  Russell,  Ann.  Surg.,  1897,  xxvi,  692,  quoted  by  Moynihan. 
^Thienhaus,  Ann.  Surg.,  1902,  x.xxvi,  928. 
^Elliot,  Ann.  Surg.,  1895,  xxii,  86. 


436  OPERATIONS    ON   THE   ABDOMEN 

"Incision  in  upper  right  linea  semilunaris.  The  gall-bladder  was  found 
empty  and  flaccid,  the  ducts  were  palpated,  and  a  stone  was  felt  deep  under 
the  liver  in  the  hepatic  duct.  The  stone  could  not  be  pushed  along  the  duct 
nor  crushed  with  the  fingers.  No  stone  was  felt  in  the  common  or  cystic 
duct.  After  separating  numerous  adhesions,  the  stone  was  shoved  between 
the  thumb  and  forefinger  of  the  left  hand  and  pulled  out  from  its  deep  position. 
Adhesions  and  duodenum  were  pushed  aside  until  the  stone  appeared  between 
the  fingers,  with  only  the  peritoneum  and  the  wall  of  the  duct  covering  it.  The 
field  of  operation  was  packed  with  gauze  to  prevent  contamination  with  bile, 
the  duct  was  incised,  and  a  stone  the  size  of  a  robin's  egg  extracted.  The 
duct  was  closed  at  once  with  catgut  sutures,  a  second  row  of  silk  sutures,  in- 
cluding the  peritoneum,  being  placed  outside;  the  duct  was  held  with  the 
fingers  and  very  Uttle  bile  escaped.  A  drainage-tube  and  gauze  were  packed 
down  to  the  sutured  duct;  the  duct  did  not  leak,  and  the  second  day  the  gauze 
drain  was  removed.  On  the  fourth  day  the  abdominal  wound  was  completely 
closed  by  provisional  sutures.     The  patient  was  well  in  three  weeks." 

HEPATICODOCHOSTOMY 

In  this  operation  the  hepatic  duct  is  opened  and  sewed  into  the 
abdominal  wound.^  Drainage  in  these  cases  is  intended  only  until  the 
flow  of  bile  can  be  reestablished  into  the  intestine  at  some  later  opera- 
tion.    No  particularly  new  features  in  after-treatment  are  noteworthy. 

HEPATICODOCHOLITHOTRIPSY 

In  this  operation  ^  the  stone  is  crushed  in  the  hepatic  duct  by  the 
fingers,  and  this  procedure  is  usually  incidental  only  to  operation  on 
some  other  portion  of  the  biliary  system.  No  special  after-treatment, 
therefore,  is  to  be  noted. 

^  Leonard  Rogers,  Brit.  Med.  Jour.,  1903,  ii,  706,  quoted  by  Moynihan. 
^  Baillet,  Bull,  et  Mem.  Soc.  de  Chir.,  xxix,  1194,  quoted  by  Moynihan. 


GUNSHOT   AND   OTHER   INJURIES    OF   THE   ABDOMEN  437 

GUNSHOT  AND  OTHER  INJURIES  OF  THE  ABDOMEN 

It  is  to  be  assumed  that  all  gunshot  wounds  of  the  abdomen  shall 
have  exploratory  operation.  This  is  true  in  civil  life,  at  least.  Treves 
found  in  the  Boer  war/  it  is  true,  that  many  cases  of  abdominal  gun- 
shot wound  which  had  undoubtedly  suffered  intestinal  injury,  endured 
prolonged  exposure,  and  tedious  transportation,  yet  recovered  with- 
out operation.  Treves  went  so  far  as  to  conclude  that  it  is  impossible 
to  operate  in  cases  in  which  the  abdomen  is  traversed  above  the 
umbilicus,  owing  to  the  multiple  character  of  the  injuries,  while  cases 
in  w^hich  the  abdomen  is  traversed  below  the  umbilicus  get  well  without 
operation.  He  advises  operation  only  when  the  bullet  has  escaped, 
so  that  its  course  is  known,  and  when  the  general  condition  is  good  and 
there  are  signs  of  abdominal  hemorrhage  continuing.  These  conclu- 
sions, however,  refer  only  to  wounds  produced  by  bullets,  such  as  the 
Mauser,  which  does  not  spread  on  impact,  is  of  small  diameter,  and 
travels  with  great  velocity.  One  surgeon  ^  found  that  Mauser  abdominal 
injuries,  when  not  immediately  fatal,  have  been  followed  by  a  recovery 
in  more  than  60  per  cent,  of  cases  under  expectant  treatment. 

In  general,  though,  every  penetrating  wound  of  the  abdominal  wall 
is  to  be  explored.  An  attempt  is  made  first  to  stop  hemorrhage.  Then 
a  systematic  search  for  injuries  of  the  viscera  is  made,  but  with  as  little 
evisceration  as  possible;  that  is,  the  intestine  examined  is  returned  to 
the  cavity  as  the  next  loop  is  pulled  out.  Wounds  in  the  alimentary 
tract  are  closed  by  linen  thread  or  silk  suture  in  every  instance,  unless 
by  so  closing  a  kink  is  produced;  in  other  words,  resection  is  avoided 
when  possible.  Drainage  should  be  instituted  in  all  cases  into  both 
kidney  pouches,  into  the  pelvis,  and  down  to  the  exact  region  of  any 
sutured  gut  about  which  the  surgeon  has  the  least  doubt  of  viability. 
If  the  lesser  omentum  has  been  opened  by  bullet  or  operation,  and 
especially  if  there  is  the  slightest  possibility  of  wounds  of  the  pancreas, 
efficient  drainage,  which,  indeed,  amounts  at  first  to  packing,  should  be 
established. 

In  most  instances  the  patient  should  be  able  to  get  on  without  nourish- 
ment for  twenty-four  to  thirty-six  hours.  During  this  period,  if  possible, 
such  peristalsis  even  as  would  be  excited  by  mild  enemas  should  be 
avoided,  though  distention  is  present  and  indication  for  enemas  exists. 
At  the  end  of  this  time  rectal  feeding  should  be  begun,  except  in  those 
instances  where  the  large  intestine  was  wounded.     Rectal  feeding  need 

^  Brit.  Med.  Jour.,  1900,  i,  1156. 

^  Spencer,  Med.  Annals,  1901,  quoted  by  Jacobson. 


438  OPERATIONS   ON   THE   ABDOMEN 

not  continue  beyond  sixty  hours  after  operation,  except  for  injuries  of 
stomach  and  duodenum.     (See  Gastro-enterostomy,  p.  411.) 

If  there  are  no  signs  of  peritonitis  or  leakage  from  the  various  repaired 
intestinal  unions,  the  wicks  may  be  withdrawn  in  forty-eight  hours. 
If  for  wicks  the  spiral  drains  (see  p.  220)  have  been  used,  they  can  be 
extracted  without  much  pain  and  without  tearing  adhesions.  Except 
in  injuries  of  the  large  intestine,  as  above  noted,  the  bowels  should  be 
evacuated  solely  by  means  of  enemas  during  the  first  ten  days.  Morphin 
should  be  used  as  little  as  necessary,  and  preferably  always  together 
with  atropin. 


CHAPTER  XLV 
OPERATIONS   ON  THE  ABDOMEN   (Continued) 

THE  RADICAL  CURE  OF  HERNIA 

The  dressing  after  operations  for  inguinal  and  femoral  hernia 
should  be  bulky  enough  to  give  some  compression  to  the  wound,  in  order 
to  prevent  oozing  of  serum  or  blood,  such  as  might  collect  bet\veen 
layers  of  muscle.  This  dressing  may  be  held  on  with  collodion,  but  I 
have  seen  the  skin,  which  in  this  region  is  especially  thin  and  sensitive 
in  some  people,  show  irritation,  even  to  the  extent  of  blistering,  after 


Fig.  137. — Abdominal  Swathe  After  Celiotomy. 
SX  is  made  to   fit  snugly  by  taking   a  "gvisset"   in    each   side   with    safety-pins.      Folded   towels  are   em- 
ployed, one  about  each  thigh,  for  perineal  straps,  and  are  pinned  over  the  anterior  superior  spine. 

■collodion  applications.  The  dressing  is  better  held  on,  therefore,  with 
strips  of  zinc-oxid  plaster  and  a  swathe  applied,  as  in  Fig.  137,  or 
with  two  T-bandages,  the  crotch  pieces  of  the  two  being  pinned  or 
tied  up  over  the  groin  on  each  side  respectively;  best  of  all,  the 
■dressing  may  be  held  on  by  a  Cunningham  hernia  spica.  (See  Figs. 
138-140,)  There  seems  to  me  to  be  not  enough  advantage  from  the 
application  of  a  broad  gauze  spica  bandage  (Fig.  141),  over  the  dressing, 
to  offset  the  possible  dangers  to  newly  sewed  muscle  layers  during  the 
manipulations  necessary  in  the  application  of  such  a  bandage.  The 
same  holds  true  of  the  piaster-of- Paris  spica  which  some  surgeons  apply 
to  maintain  flexion  of  the  thigh.  AMiatever  form  of  outside  dressing  is 
applied,  care  should  be  taken  that  the  testicles  and  scrotum  are  well  sup- 

439 


440 


OPERATIONS    ON    THE    ABDOMEN 


ported  and  their  blood-supply  not  interfered  with,  otherwise  hematoma 
or  gangrene  may  result.     The  patient  should  be  put  to  bed,  with  the 


Fig.  138. — Application  of  the  Cunningham  Hernia  Spica. 
To  one  end  of  a  strip  of  Shaker  flannel  6  in.  wide  and  14  in.  long  is  sewed  a  strip  of  zinc-oxid  plaster  of  the 
same  width  and  24  in.  long;  at  the  other  end  of  the  flannel  a  piece  14  in.  long.  The  application  is  started  by 
so  placing  the  midsection  of  flannel  under  the  slighfly  flexed  thigh  and  in  the  crotch  that  the  short  plaster  end 
is  carried  over  the  dressing  to  the  loin  on  the  operated  side;  the  long  plaster  end  crosses  the  dressing  to  the 
opposite  loin. 


Fig.  139. — CrxxiNGHAM  Hernia  Spica. 
The  two  adhesive  plaster  strips  cross  over  the  dressing. 

thigh  slightly  flexed  by  means  of  a  pillow  under  the  knee  to  a\'oid  un- 
necessary strain  on  the  lines  of  sutures.  The  patient  should  be  kept 
practically  horizontal;    every  means  should  be  taken  to  avoid  cough. 


THE    RADICAL    CURE    OF    HERNIA 


441 


efforts  toward  sitting  up,  or  straining  at  stool;   the  bowels  should  be 
moved  by  enemas  only  for  the  first  ten  days  for  this  reason. 


Fig.  140. — Cunningham  Hernia  Spica. 
The  long  end  being  applied  to  the  opposite  loin. 


The  single  intracuticular  stitch  should  be  removed  about  the  tenth 
day.  The  patient  should  not  get  up  before  the  fourteenth  day,  and 
many  surgeons  make  three  weeks  in  bed  the  rule  after  inguinal  herni- 


EiG.  141. — Applying  the  Gauze  Spica  Dresstxg  Afti:i<  HiaiNKnuMN-. 

otomy  in  men;  he  should  avoid  heavy  lifting  for  three  months  if  possible. 
In  children  under  five  or  six  years  of  age  who  are  hard  to  control  it  is 
probably  best  to  apply  the  plastcr-of-Paris  spica  bandage  outside  the 


442  OPERATIONS    ON    THE    ABDOMEN 

dressing  to  assist  in  immobilizing.  These  directions  apply  to  all  varie- 
ties of  operation:  the  Johns  Hopkins  operation/  the  Bassini  operation,^ 
the  autoplastic  suture  method  of  McArthur/  and  femoral  hernial 

Retroperitoneal  hernia,  whatever  the  operation/  calls  for  no  special 
after-treatment  except  the  general  considerations  of  celiotomy  and 
intestinal  surgery. 

After  the  operation  for  obturator  hernia  ^  no  special  details  of  after- 
treatment  are  to  be  noted.  The  stay  in  bed  should  be  the  full  three 
weeks. 

Epigastric  hernia  '^  presents  only  the  problems  of  simple  celiotomy. 

Interstitial  hernia^  whether  ventral  or  inguinal,  calls  for  no  detail 
of  after-treatment  different  from  those  already  given. 

Umhilical  hernia  ^  is  undoubtedly  best  treated  by  the  operation  of  the 
type  of  Mayo.  The  dressing  after  this  operation  and  that  for  ventral 
hernia  should  be  held  on,  and  all  tension  on  the  wound  removed  by  the 
application  of  a  large  number  of  plaster  straps  in  many  directions,  and 
also  by  a  snugly  pinned  abdominal  swathe.  There  is  probably  no  in- 
crease of  pressure  if  the  patient  sits  partly  reclining  on  a  bed-rest,  if  such 
a  position  is  more  comfortable.  The  bowels  should  be  kept  freely  open 
by  enemas  to  avoid  all  straining  at  stool.  The  skin  stitches  are  removed 
on  the  tenth  day;  the  wound  is  kept  reinforced  by  plaster  straps  for  at 
least  three  weeks,  and  an  abdominal  belt  is  usually  advised.  The 
patient  should  be  in  bed  at  least  eighteen  days. 

Complications  and  Sequelae. — Pulmonary  or  cardiac  embolism 
are  always  fearful  possibilities,  more  probably  if  a  large  hernia  of  long 
standing  has  been  reduced  or  if  a  considerable  mass  of  omentum  has 
been  tied  off  and  removed.     (See  Large  Incarcerated  Hernia,  p.  443.) 

Truss  After  Radical  Cure  for  Hernia. — Drs.  Bull  and  Coley 
say:  "Personally,  we  never  advise  a  truss  in  children  after  operation,  and 
we  consider  the  recumbent  position  for  three  months  entirely  unneces- 
sary. Our  experience,  based  on  a  series  of  upward  of  600  cases  of 
hernia  in  children  under  fourteen  years  of  age,  has  shown  that  t^vo  to 
two  and  a  half  weeks  is  ample  time  for  the  child  to  remain  in  bed.     The 

^  Halsted,  Johns  Hopkins  Hosp.  Bull.,  1903,  xiv,  208. 
^  E.  Bassini,  Arch.  f.  klin.  Chir.,  1890,  xl,  429. 
^  L.  L.  McArthur,  Jour.  Amer.  Med.  Assoc,  1904,  xliii,  1039. 
*  Hayward  W.  Gushing,  Boston  Med.  and  Surg.  Jour.,  1888,  cxix,  546. 
^  B.  G.  A.  Moynihan,  Retroperitoneal  Hernia,  London,  1899,  reviewed  in  Ann.  Surg., 
1903,  xxxvii,  120. 

^  Schopf,  Wien.  klin.  Woch.,  1903,  xvi,  8. 

^  H.  A.  Lothrop,  Boston  Med.  and  Surg.  Jour.,  1901,  cxlv,  589-611. 

^  P.  Berger,  Re^oie  de  Chir.,  Paris,  Jan.,  1902. 

"  W.  J.  Mayo,  Ann.  Surg.,  Aug.,  1901,  xxxiv. 


LARGE    INCARCERATED    HERNIA  443 

subsequent  history  of  these  cases  has  been  traced  with  scrupulous  care, 
and  some  of  them  have  been  well  upward  of  seven  years.  Even  in 
adults  we  very  seldom  advise  a  truss  after  operation.  There  are,  how- 
ever, some  cases  in  which  a  permanent  cure  will  be  more  likely  to  be 
obtained  if  a  support  be  worn  after  operation.  Such  cases  are  those, 
beyond  middle  age,  with  poorly  developed  and  flabby  abdominal  muscles 
and  a  superabundance  of  fat.  We  would  also  include  cases  in  which 
hernia  is  of  unusual  size  in  adults  past  middle  life." 

It  would  seem  reasonable,  therefore,  where  an  operation  fairly  satis- 
factory to  the  operator  has  been  done,  to  await  signs  of  recurrence  before 
ordering  a  truss.  Certainly  the  abdominal  belt,  with  a  plate  in  it 
pressing  over  the  scar,  is  not  to  be  advised.  It  causes  local  pressure 
ischemia,  and,  therefore,  slow  healing  of  the  wound,  and  renders  the 
abdominal  muscles  more  flabby  and  more  liable  to  stretch.  A  hernia 
patient  should  be  advised  to  avoid  strenuous  exercise  in  a  position  such 
as  would  tend  to  open  possible  hernial  orifices.  For  instance,  he  may 
be  advised  not  to  lift  heavy  things  unless  his  knees  are  kept  together; 
not  to  lift  himself  up  by  his  hands,  as  in  horizontal  bar  exercises  or 
climbing  a  mast. 

In  children  under  two  years  inguinal  hernia  can  frequently  be  cured 
by  the  use  of  a  truss.  For  this  purpose  a  worsted  truss  is  to  be  advised 
because  of  the  cheapness  and  cleanliness.  When  soiled,  it  can  be  changed 
and  washed;  it  can  be  worn  in  the  bath,  and  is  less  likely  to  irritate  the 
skin  than  a  spring  truss.  To  apply  such  a  truss  the  child  is  laid  on  his 
back  and  the  hernia  reduced,  a  half  skein  of  white  Germantown  worsted 
is  passed  under  the  body  at  the  level  of  the  hernia,  and  is  pulled  through 
until  the  end  on  the  side  of  the  hernia  just  reaches  the  internal  ring; 
the  other  end  is  passed  through  the  loop  of  the  first  end,  the  bunch  of 
worsted,  made  by  looping  one  end  through  the  other,  is  then  adjusted 
firmly  over  the  hernial  opening,  and  the  free  end  is  passed  under  the 
crotch  and  fastened  by  a  safety-pin  or  a  bit  of  bandage  to  the  middle  of 
the  part  passed  around  the  back.  This  truss  should  fit  snugly,  and 
should  be  worn  at  night  as  well  as  during  the  day.  The  success  of  this 
method  depends  upon  the  care  with  which  the  mother  carries  out  in- 
structions in  regard  to  adjusting  the  truss  frequently. 

LARGE  INCARCERATED  HERNIA 

The  fatal  issue  in  many  of  these  cases  is  due  to  the  sudden  and  marked 
increase  of  intra-abdominal  pressure,  especially  limiting  the  function 
of  the  diaphragm,  which  follows  the  reintroduction  into  an  abdomen, 
which  has  long  since  become  too  small  to  hold  it,  of  a  large  mass  of  in- 


/^/|4  OPERATIONS   ON   THE   ABDOMEN 

testine  and  fatty  omentum.  If  it  seems  best  to  operate  these  cases,  they 
should  be  submitted  for  a  considerable  period,  whenever  possible,  to  a 
regimen  that  shall  definitely  reduce  weight.  By  these  means  the  mesen- 
teric fat  diminishes  and  the  abdominal  wall  becomes  thin. 

The  following  history,  which  illustrates  this  point,  is  by  the  French  surgeon,  George 
i^rnaud,  who  pubHshed  in  1748  "A  Dissertation  on  Hernias  or  Ruptures,"  quoted  by 
Marcy  (Ann.  Surg.,  1900,  xxxi,  71): 

"Mr.  Boudon  recommended  to  my  deceased  father  a  man  of  forty  years  of  age  and 
of  a  very  strong  constitution.  He  was  extremely  fat  and  6  ft.  i  in.  in  height,  French 
measure.  His  name  was  Mr.  Tregneux,  was  an  inhabitant  of  Clamsey,  in  the  diocese  of 
Auxerre.  He  had  an  hernia  from  his  infancy,  which  had  never  reentered.  It  was  32  in. 
in  circumference  at  its  lowest  part,  19  at  the  ring,  and  16  in  length.  For  more  than  ten 
years  his  penis  had  been  lost  in  the  bulk  of  the  tumor,  so  that  the  preputium  formed  a  kind 
of  depression  Mke  that  of  the  navel,  and  in  making  water  his  urine  was  diffused  over  all 
the  tumor,  which  was  very  troublesome  to  him.  As  he  was  a  timber  merchant,  his  business 
obliged  him  almost  every  day  to  ride  forty  or  fifty  miles  on  horseback,  which  induced  him 
to  invent  a  large  cavity  in  the  fore  part  of  his  saddle,  in  which  he  placed  his  tumor.  Being 
at  last  reduced  to  such  a  condition  that  he  could  no  longer  follow  his  business,  and  being 
afraid  that  this  disorder,  no  less  terrible  than  insupportable,  would  soon  put  an  end  to  his 
life,  he  determined  to  apply  for  rehef.  It  was  in  1726  that  he  was  introduced  to  us.  He 
found  a  great  deal  of  comfort  from  the  recent  example,  which  my  father  and  I  gave  him, 
of  the  cure  of  a  similar  disorder.  He  submitted  to  everything  we  prescribed,  either  for 
his  relief  or  radical  cure,  but  on  condition,  said  he,  that  he  should  have  a  little  to  eat,  for 
he  was  a  prodigious  glutton.  Persons  of  this  kind  may  observe  a  very  strict  regimen, 
even  by  eating  a  little.  We  may,  therefore,  recede  from  the  general  rule  in  their  favor 
without  any  fear  of  doing  harm,  for  their  great  appetite  requires  this  kind  of  hberty.  He 
was  bleeded  several  times,  then  purged,  and  afterward  used  12  or  15  baths.  Twice 
a  day  I  made  strong  embrocations  of  his  abdomen  with  oil  of  melilot,  and  covered  the 
whole  tumor  with  a  plaster  composed  of  the  emplastrum  de  vigo,  prepared  with  a  good 
deal  of  mercury,  of  the  diabotanum,  and  the  mucilages,  and  this  I  renewed  every  four 
days.  We  made  him  every  morning  take  10,  12,  15,  or  20  gr.  of  mercur.  dulc.  He  drank 
plentifully,  and  had  four  emollient  and  purgative  clysters  injected  every  day.  Every  four 
days  we  purged  him  with  cassia,  mth  an  intention  to  evacuate  the  humors  and  prevent 
a  salivation.  This  method  succeeded  very  happily,  for  the  evacuations  lasted  sixteen 
days,  and  were  so  copious  that  they  every  day  redoubled  the  patient's  astonishment. 

"The  tumor  during  this  time  had  lost  about  three-quarters  of  its  bulk,  and  more  than 
a  half  of  the  remaining  quarter  we  made  to  reenter  by  taxis,  so  that  the  hernia,  being  thus 
reduced  to  one-eighth  part  of  its  bulk,  was  in  a  condition  to  be  contained  in  the  hollow 
cushion  of  a  truss. .  It  afterward  diminished  insensibly  for  eight  or  ten  days,  during  which 
time  we  took  care  to  fill  the  cavity  of  the  cushion,  in  proportion  as  the  bulk  of  the  tumor 
diminished.  On  the  thirty-sixth  day  from  the  first  venesection  the  parts  reentered  all 
together  and  the  testicle  also.  We  then  used  a  convex  instead  of  the  concave  cushion. 
The  patient  in  a  very  short  time  resumed  his  strength  and  flesh,  and  followed  his  business 
with  a  great  deal  more  vigor  than  ever  he  had  done.  The  first  thing  he  did  at  his  return 
home  was  to  make  his  wife  pregnant,  with  whom  he  had  had  no  amorous  converse  for  ten 
years  before.  He  quitted  the  use  of  the  truss  eighteen  months  after;  that  is  to  say,  in 
1728. 

"Twelve  years  after,  he  had  occasion  to  come  to  Paris,  where  he  called  for  me  immedi- 
ately on  his  arrival,  rather  to  testify  his  gratitude  than  for  any  other  reason;  but  as  I  did 
not  know  him,  he  put  me  in  mind  of  everything  that  had  happened  in  1726.  I  examined 
the  parts,  which  I  found  so  firm  and  solid  that  one  could  have  hardly  imagined  that  he  had 
formerly  labored  under  an  hernia.     The  skin  of  the  scrotum  was  returned  to  its  natural 


STRANGULATED   HERNIA    (INGUINAL    OR   FEMORAL)  445 

state,  only  it  was  very  thick;  and  the  bottom  of  the  scrotum,  which  had  approached  to 
the  ring  on  account  of  the  herniary  sac  of  the  testicle,  was  fixed  or  glued  over  the  ring. 
This  portion  of  skin  seemed  to  make  a  kind  of  stopper,  which  filled  the  cavity  of  it.  But, 
though  the  disorder  had  no  appearance  of  a  relapse,  I  ordered  the  patient  to  wear  a  truss 
by  way  of  prevention.  The  reason  of  which  I  shall  afterward  give  in  a  particular  instance. 
From  this  observation  it  is  sufficiently  evident  that  what  at  first  appeared  a  paradox  is  a 
truth  easily  perceived  by  persons  of  penetration;  but,  as  it  may  perplex  the  more  ignorant 
and  illiterate  part  of  mankind,  I  shall,  for  their  sake,  render  it  still  more  intelligible  by  a 
method  of  reasoning  as  clear  and  perspicuous  as  I  possibly  can. 

"The  parts  had  insensibly  accustomed  themselves  to  this  new  abdomen  which  nature 
had  formed  for  them.  They  had  there  fixed  a  permanent  residence  for  themselves,  whence 
it  was  impossible  for  them  to  remove  on  account  of  the  adherences  they  had  contracted. 
Without  the  methodical  assistance  afforded  it  was  impossible  that  they  should  ever  of  them- 
selves have  reentered  the  abdomen,  but  by  the  disposition  into  which  they  were  put  they 
were  forced  to  resume  their  natural  place,  though  they  were  lean  and  emaciated,  yet  when 
they  were  reduced,  they  resumed  their  former  bulk,  in  the  same  proportion  as  all  the  other 
parts  of  the  body  resumed  their  flesh.  Now  they  could  not  slip  out  again,  after  they  were 
once  in  the  abdomen,  because  they  were  become  larger  than  the  diameter  of  the  ring,  so 
that  the  patient  must  necessarily  have  been  cured  long  before  he  left  off  the  use  of  the  truss. 
The  following  fable  applied  to  this  subject  will  more  sensibly  enable  us  to  comprehend 
what  hinders  these  sorts  of  hernias  from  reentering  and  what  obliges  them  to  remain  in  the 
abdomen  after  they  are  reduced. 

"'Into  a  wicker  cask,  where  corn  was  kept, 

Perchance  of  meagre  crops,  a  field  mouse  crept; 

But  when  she  fill'd  her  paunch,  and  sleek'd  her  hide, 

How  to  get  out  again,  in  vain  she  try'd. 

A  weasel  who  beheld  her  thus  disturb'd, 

In  friendly  strain  the  luckless  mouse  address'd, 

'Would  you  escape,  you  must  be  poor  and  thin. 

To  pass  the  hole  thro'  which  you  entered  in.'" 

(Horace,  Lib.  I,  Epist.) 

After  operation  the  patient  should  be  sat  up  at  once  in  bed  with 
proper  support  to  the  wound,  to  diminish  diaphragmatic  pressure  and 
to  forestall  the  occurrence  of  thrombosis  and  pneumonia.  An  abdominal 
swathe  should  be  worn  for  six  months  at  least,  and,  in  especially  gross 
patients,  permanently. 

Cardiac  embolism  and  thrombosis  or  pulmonary  embolism  are  much 
to  be  feared,  especially  if  the  hernia  was  largely  omentum  and  much 
was  resected.     For  an  illustrative  case  see  Chapter  IX,  p.  io6. 

STRANGULATED  HERNIA  (INGUINAL  OR  FEMORAL) 

The  patient  should  be  kept' in  such  a  position  in  the  bed  that  there 
is  little  or  no  strain  on  the  wound.  It  is  theoretically  good,  at  least,  to 
have  the  buttocks  slightly  raised  above  the  level  of  the  trunk,  in  order 
that  the  reduced  bo^^'el  may  not  lie  in  contact  with  the  freshly  sewed 
ring  and  so  become  adherent  to  it.  The  patient  should  be  given  water 
freely  as  soon  as  it  can  be  borne  by  the  stomach,  but  no  voluminous 


446 


OPERATIONS   ON   THE   ABDOMEN 


food-masses  should  be  taken  in  for  at  least  a  week,  in  order  that  the  in- 
jured gut  may  have  a  chance  to  heal.  The  bowels  should  be  moved  by 
enemas  only,  in  order  that  no  violent  peristalsis  shall  take  place  above 
the  level  of  the  injured  gut.  Even  though  such  a  wound  as  that  of 
strangulated  hernia  is  supposed  to  be  aseptic,  it  should  not  be  allowed 
to  go  a  week  or  ten  days  without  inspection;  first,  because  the  effort  to 
reduce  the  strangulated  gut  or  the  spilling  of  the  serous  content,  so 
often  seen  in  the  sac,  may  have  infected  the  wound  to  some  extent; 


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and,  second,  especially  if  the  patient  be  an  elderly  person,  there  may 
be  no  sign  in  temperature  or  pain  to  suggest  sepsis,  and  yet  examination 
of  the  wound  shows  a  considerable  and  wide-spread  infection. 

After  the  first  few  days,  if  it  has  been  possible  at  the  time  of  operation 
to  make  a  radical  cure,  the  case  should  receive  the  usual  after-treatment 
of  a  hernia  operation.     (See  p.  439.) 

If  the  condition  of  the  gut  was  such  that  it  seemed  best  to  drain 
the  wound,  or  if,  as  may  be  the  case  in  strangulated  femoral  hernia,  so 
much  of  Gimbernat's  ligament  had  to  be  cut  that  there  is  little  chance 


OPERATIONS   ON   THE   PANCREAS  447 

that  an  efficient  closing  of  the  defect  has  been  made,  it  is  well,  while  the 
patient  is  still  in  bed,  to  have  him  measured  and  fitted  to  a  truss,  with 
the  idea  of  allowing  him  to  get  out  and  about  for  a  time,  and  later,  if 
necessary,  have  him  come  back  for  a  secondary  operation. 

Complications  and  Sequelae.— (i)  Peritonitis.— This  may  be 
due  to  the  operation  having  been  done  too  late,  infection  taking  place  by 
actual  rupture  of  the  bowel  or  from  transudation  from  the  strangulated 
part,  or  from  the  reduction  of  hernial  contents,  bowel,  or  omentum, 
which  seem  to  the  operator  to  be  viable,  but  are  not  so. 

(2)  Sepsis. — Local  sepsis  is  fairly  common  in  cases  not  operated 
within,  a  very  few  hours.  This  comphcation  calls  for  no  special  com- 
ment here. 

(3)  The  descent  and  restrangulation  of  the  bowel  where  radical  cure 
was  not  attempted. 

(4)  Obstruction  due  to  paralysis  of  the  damaged  intestine. 

(5)  Unobserved  reduction  en  bloc  of  the  hernia  during  operation,  or 
multilocular  hernial  sac  with  a  false  reduction  during  operation  from 
one  part  of  the  sac  to  another. 

Reduction  "en  bloc"  is  chiefly  met  in  inguinal  hernia  owing  to  the 
slight  surrounding  adhesions  of  the  sac  and  sometimes  to  the  force  used 
in  attempts  to  reduce  large  herniae.  The  sac,  still  strangulating  its 
contents  at  its  neck,  is  displaced  bodily  between  the  peritoneum  and  the 
muscles;  or  the  sac  is  rent  close  to  its  neck  and  at  its  posterior  aspect, 
and  some  of  its  contents  are  thrust  through  into  the  extraperitoneal 
connective  tissues.  The  chief  evidence  of  this  occurrence  is:  though 
the  swelling  has  disappeared  perhaps  completely,  this  has  taken  place 
without  the  characteristic  jerk  or  gurgle.  On  close  examination,  though 
the  bulk  of  the  hernia  has  gone,  some  swelling  is  to  be  made  out  deep 
near  the  internal  ring,  and  the  symptoms  persist  in  an  intensified  form. 
A  second  operation  should  be  done  immediately. 

(6)  Obstruction  of  the  intestine  by  adhesions  to  the  abdominal  wall. 

(7)  Cicatricial  stricture  of  the  gut  at  the  site  of  former  strangulation. 
These  possible  pathologic  features  must  be  in  the  mind  of  one  who 

watches  symptoms  after  operations  for  strangulated  hernia. 

OPERATIONS  ON  THE  PANCREAS 

Acute  Pancreatitis. — The  wound  in  this  fairly  uncommon  and 
frequently  fatal  disease  is  packed  with  gauze,  which  acts,  first,  to  stop 
bleeding,  and,  second,  to  establish  a  drainage  tract.  Drainage  in  cases 
of  subacute  pancreatitis,  and  often  also  in  pancreatic  cyst,  is  estab- 
lished by  the  so-called  lumbar  route;  namely,  through  a  loin  incision  in 


448  OPERATIONS  ON  THE  ABDOMEN 

front  of  the  left  renal  vessels.  Such  a  .wound  follows  the  route  usually 
taken  by  nature  when  pancreatic  suppuration  points  spontaneously. 
The  wound  drains  freely  assisted  by  gravity,  and  presents  no  technical 
peculiarities,  if  the  first  wicks  are  left  in  long  enough  to  favor  a  large 
direct  drainage  opening. 

Shock,  sepsis,  and  hemorrhage  are  all  here  present,  and  are  hardly 
to  be  differentiated  in  importance.  The  usual  indications  thus  suggested 
must  be  followed.  Most  of  the  dangers  should  be  over  by  the  end  of  the 
fourth  day,  after  which  convalescence  should  be  rapid. 

The  wicks  should  gradually  be  withdrawn  and  made  smaller.  If 
there  is  no  contraindication,  the  sooner  the  patient  is  out  of  bed  the 
better. 

Complications  and  Sequelae. — (i)  Delayed  and  secondary 
hemorrhage  are  very  common,  owing  to  the  extreme  vascularity  of  the 
pancreas.  This  danger  is  so  great  that  it  may  indeed  be  wise  to  exhibit 
large  doses  of  calcium  lactate  (see  Chapter  VI,  p.  68)  in  operative 
cases  where  the  diagnosis  is  made  and  time  permits. 

(2)  "In  leakage  of  pancreatic  Juice  into  the  parenchyma  of  the  gland 
and  the  surrounding  peritoneal  structures  consists  a  greater  danger 
even  than  bleeding.  The  juice,  even  when  sterile,  does  much  positive 
damage,  which  also  diminishes  the  resisting  power  of  the  tissues  so  that 
the  mildest  form  of  infection,  ordinarily  harmless,  becomes  of  the  gravest 
significance.  Infection  is  liable  to  reach  the  injured  area  through  the 
pancreatic  duct  from  the  duodenum,  in  the  same  manner  that  it  passes 
up  the  comm_on  bile-duct;  fat  necrosis  and  pancreatitis,  both  chronic 
and  hemorrhagic,  may  be  occasioned  by  trauma  and  hence  may  result 
from  operation.  Peritonitis  is  very  liable  to  result  from  pancreatic 
leakage.  This  peritonitis  may  be  aseptic,  and  is  followed  frequently 
by  intestinal  paralysis,  leading  to  rapidly  developing  obstruction,  which 
often  so  modifies  the  symptoms  as  to  lead  to  a  serious  mistake  in  diag- 
nosis." ^ 

Wounds  of  the  Pancreas. — Any  wound  of  the  posterior  stomach- 
wall  suggests  that  the  same  agent  has  made  a  wound  of  the  pancreas. 
Such  a  wound,  therefore,  is  always  sought,  and  if  found,  is  packed  with 
a  view  to  establishing  drainage,  because  of  the  great  danger  of  pancreatic 
leakage  even  through  a  small  wound. 

DRAINAGE  OF  PANCREATIC  CYST 

These  cysts  are  always  drained,  and  such  evidence  as  we  have  seems 
to  show  that  some  must  be  permanently  drained,  since,  at  least  in  those 

^  Von  Mikulicz,  Trans.  Cong.  Am.  Surg,  and  Phys.,  1903. 


DRAINAGE    OF   PANCREATIC    CYST  449 

cases  where  many  of  the  principal  ducts  of  the  pancreas  communicate 
with  the  cyst,  recurrence  is  almost  certain  and  complete  obliteration 
by  drainage  almost  impossible.  In  Mr.  Jacobson's  case^  the  swelling 
reappeared  about  a  year  later,  and  is  even  said  to  have  appeared  a  third 
time  after  the  second  operation. 

Dr.  M.  H.  Richardson^  some  years  ago  called  attention  to  this  lia- 
bility to  recurrence  in  drained  pancreatic  cysts: 

"  The  patient  was  twenty-one.  He  had  received  a  kick  in  the  abdomen 
three  years  before,  which  had  confined  him  to  bed  for  three  weeks.  Ever 
since  he  had  been  liable  to  suffer  attacks  of  epigastric  pain.  He  had  been 
markedly  jaundiced,  was  emaciated,  and  suffered  a  good  deal  from  nausea 
and  depression.  The  swelUng  in  the  epigastric  region  was  convex  and  uni- 
form, and  reached  from  below  the  tip  of  the  ensiform  cartilage  to  just  above 
the  umbilicus,  and  laterally  to  near  the  ends  of  the  eleventh  rib.  The  tumor 
gave  the  impression  of  being  attached  to  some  deep-seated  structure.  There 
was  transmitted  impulse  synchronous  with  the  pulse,  but  not  expansible. 
As  the  swelling  had  refilled  after  two  previous  tappings,  and  as  the  swelling 
and  the  patient's  distress  were  steadily  increasing,  laparotomy  was  performed. 
An  incision  3  in.  long  was  made  over  the  most  prominent  part  of  the  cyst, 
i^  in.  to  the  left  of  the  middle  line,  extending  to  within  i  in.  of  the  umbilicus. 
The  parietal  peritoneum  having  been  retracted  to  the  margins  of  the  wound, 
the  lower  edge  of  the  liver  could  be  seen  moving  with  respiration  in  the  upper 
angle,  while  the  rest  of  the  incision  was  occupied  by  a  smooth  reddish  surface 
which  bulged  strongly  forward.  Taking  this  to  be  the  front  of  the  cyst,  and 
having  ascertained  before  the  operation  that  the  cyst  was  dull  on  percussion, 
I  was  about  to  leave  this  for  twenty-four  hours,  to  become  adherent  before 
it  was  incised.  The  result  proved  that,  if  I  had  done  so,  the  scalpel  would 
have  passed  through  both  walls  of  the  stomach.  Before  dressing  the  wound 
I  again  scrutinized  the  surface  of  the  supposed  cyst,  and  thought  I  found 
evidence  of  involuntary  muscular  fiber,  which  threw  doubts  upon  the  swelling 
being  a  pancreatic  cyst.  When  the  supposed  cyst  was  examined  between  the 
fingers,  it  proved  to  be  the  empty  stomach,  stretched  very  tightly  over  the 
subjacent  cyst.  To  get  at  this  the  stomach  was  drawn  upward,  that  it  might 
be  packed  away  above  under  the  liver;  but  here  an  embarrassing  difficulty 
arose.  As  I  pulled  up  the  stomach,  it  was  tightly  jammed  between  the  bulg- 
ing cyst  behind  and  the  parietes  in  front;  the  omentum  came  up  into  the 
wound  in  front  of  the  cyst.  The  tension  on  the  parts  was  so  great,  o\\ing  to 
the  rapid  increase  in  the  cyst,  that  there  was  no  room  above  in  which  to  pack 
away  the  omentum.  Pushing  this  to  either  side,  already  fully  occupied,  I 
pulled  down  the  stomach  again.     I  accordingly  drew  the  greater  part  of  the 

*  Jacobson,  Trans.  Med.  Chir.  Soc,  Ixxivj  455 
^  Boston  Med.  and  Surg.  Jour.,  1892,  cx.xvi,  441. 

29 


450  OPERATIONS   ON   THE   ABDOMEN 

omentum  out  of  the  wound,'  some  of  which  was  tied  with  catgut,  and  cut  away; 
most  of  it  was  left  heaped  up  on  the  abdominal  walls  on  either  side  of  the  in- 
cision. One  or  two  fine  catgut  sutures  retained  the  omentum  in  position. 
I  next  scraped  through  the  two  layers  of  the  omentum,  and  exposed  the  sur- 
face of  the  cyst  for  a  space  the  size  of  a  quarter.  There  was  thus  a  some- 
what conical  passage  leading  from  the  abdominal  incision,  through  a  mass  of 
omentum,  down  to  the  anterior  surface  of  the  cyst.  This  last  was  very  vas- 
cular, and  so  tense  that  it  was  not  thought  advisable  to  put  in  a  guide  suture. 
The  patient  passed  through  the  next  twenty-four  hours  fairly  well.  At  mid- 
night, August  23d,  symptoms  of  collapse  set  in  (hemorrhage  probably  took 
place  at  this  time  into  the  cyst,  a  complication  which  must  always  be  probable, 
owing  to  the  very  vascular  surroundings) ;  the  patient's  pulse  at  2  A.  M.  had 
run  up  to  163,  and  his  condition  pointed  to  a  fatal  ending  at  no  distant  date. 
At  3  A.  M.  I  passed  a  fine  trocar  into  the  cyst,  and  drew  off  12  oz.  of  deeply 
blood-stained  fluid  under  very  high  tension.  The  sac  was  then  incised  and  a 
large  drainage-tube  inserted.  A  marked  improvement  at  once  set  in.  A 
slight  discharge  of  dark,  treacley  fluid  necessitated  changing  the  dressing  twice 
a  day  at  first.     The  wound  was  all  healed  in  two  months." 

«  SPLENECTOMY 

This  operation  has  been  done- — (i)  for  large  wounds  of  the  spleen 
from  gunshot  or  other  injury;  (2)  for  cyst,  though  this  rare  condition  if 
drained  will  always  heal;  (3)  for  movable  spleen;  (4)  for  malignant  dis- 
ease; (5)  for  persistent  malarial  tumor;  (6)  for  splenic  anemia  or  leuke- 
mia. Of  all  these  indications,  the  most  favorable  is  that  of  injury. 
Otherwise  healthy  persons  with  spleen  removed  seem  to  live  on  for  years 
in  perfect  health,  with  no  physiologic  changes  to  be  observed,  even  in 
the  blood. 

Complications  and  Sequelae. — (i)  Secondary  hemorrhageha,sheen 
repeatedly  observed,  and  apparently  in  every  case  it  has  been  due  to 
retraction  of  one  or  more  vessels  from  the  pedicle.  In  such  cases  the 
pedicle  has  been  tied  when  tense  or  each  ligature  has  taken  in  too  great 
a  portion  of  the  pedicle.  Hemorrhage  may  take  place,  due  to  general 
ooze  from  the  cavity  in  which  the  spleen  was  adherent  or  from  adherent 
omentum.  Should  the  stasis  at  the  end  of  operation  be  in  any  way 
unsatisfactory,  the  cavity  must  be  packed  for  twenty-four  to  forty-eight 
hours. 

(2)  Sepsis. — There  is  no  particular  liability  to  sepsis  after  splenec- 
tomy. There  have  been  some  observations  which  seem  to  show  that  the 
spleen  is  at  least  one  of  the  organs  which  is  important  in  the  work  of 

^  "  On  another  occasion  I  should  divide  the  omentum  by  the  transverse  colon." 
^  J.  Pollins  Warren,  Ann.  Surg.,  1901,  xxxiv,  521. 


APPENDICOSTOMY 


451 


!?: 

t^ 

f 

M 

r 

0 

3 

"2 

5' 

B 
•0 

E      2;      3 


resistance  against  bacteria,  but  it  is  "proper  to  conclude  that  the  removal 
of  the  spleen  does  not  alter  particularly  the  individual  susceptibility  to 
infection,  and  that  its  functions  in  this 
respect,  if  they  do  .  actually  exist  on 
its  removal,  are  readily  taken  up  by 
other  organs."  ^ 


May  22,  1907,  I  operated  F.  A.  R., 
thirty-six,  male,  for  spleen  ruptured  in  an 
automobile  accident.  Splenectomy  was 
done;  drainage  left  in  forty-eight  hours. 
Convalescence  was  complicated  by  abscess 
of  left  lung,  which  to  some  extent  must 
have  modified  the  blood  count.  The  man 
recovered  in  due  time  and  is  active  and 
well  at  the  present  day  (Jan.,  1910),  with 
no  apparent  physiologic  abnormality.  The 
blood  counts  are  shown  in  table. 


"^ 


>^ 


APPENDICOSTOMY 

This  operation  was  first  proposed 
by  Keetley,^  who  suggested  that  by 
bringing  the  appendix  through  the 
abdominal  wall  and  amputating  the 
apex  it  might  be  used  as  a  spout  to 
relieve  the  distention  of  a  case  of  ob- 
struction occurring  at  a  point  below  the 
cecum.  The  first  operation  was  done, 
however,  by  Weir,^  who  used  it  for 
treatment  in  a  case  of  ulcerative  colitis. 
In  brief,  the  appendix  is  brought  out 
through  a  small  incision,  which  must 
not  be  of  the  McBurney  type,  lest 
muscle  contracture  cause  slough  of  the 
appendix.  Care  being  taken  to  avoid 
twists  or  constrictions  of  the  appendix, 
it  is  pulled  out  until  the  cecum  is  in 
contact  with  the  parietal  peritoneum. 

Two  or  'three  days  later,  without  anesthesia,  the  tip  of  the  appendix 
is  severed  within  I  in.  of  the  skin  and  any  bleeding  point  secured.     The 

.*  J.  C.  Hubbard,  Boston  Med.  and  Surg.  Jour.,  1909,  clx,  746. 

^Brit.  Med.  Jour.,  1894,  ii,  1155.  ^  New  York  Med.  Record,  Aug.  9,  1902. 


452  OPERATIONS    ON    THE    ABDOMEN 

exposed  mucous  membrane  is  caught,  pulled  out  a  little,  and  fastened 
by  one  or  two  stitches  to  the  edge  of  the  skin.  A  rubber  catheter  is 
introduced  into  the  cecum,  and,  if  desirable,  irrigation  or  other  treatment 
can  be  given  at  once.  If  the  lumen  is  small,  it  will  readily  dilate  with  a 
catheter.  Immediate  opening  of  the  appendix  at  the  first  operation 
may  be  done,  if  necessary,  with  little  danger.  An  illustrative  case  will 
probably  best  show  the  post-operative  details  of  appendicostomy. 

"A  fish-hawker,  aged  twenty-six,  who  had  been  a  soldier,  and  had  had 
two  attacks  of  dysentery,  in  Africa  in  1900  and  in  India  in  1906,  complained 
of  six  to  eight  motions  of  blood  and  slime  daily,  without  pain  and  with  no 
marked  emaciation.  His  general  condition  was  excellent;  the  sigmoidoscope 
showed  considerable  edema  of  the  tissue,  with  marked  inflammation  of  the 
mucous  membrane  and  superficial  ulceration,  especially  marked  at  places 
exposed  to  friction,  such  as  the  edges  of  the  rectal  folds. 

"Appendicostomy  was  performed  on  July  23,  1907,  by  Mr.  S^A^nford 
Edwards.  Four  days  later  irrigation  was  started,  6  pints  of  weak  boric  lotion 
being  slowly  allowed  to  flow  through  the  catheter  into  the  cecum.  A  moderate- 
sized  vulcanite  tube  was  passed  through  the  sphincter  for  about  3  in.  The 
inflow  was  regulated  so  as  not  to  allow  of  too  great  distention,  and  abdominal 
massage  along  the  course  of  the  great  gut  employed.  After  about  six  minutes 
the  lotion  began  to  flow  from  the  rectum,  bringing  with  it  fragments  of  feces. 
Before  the  outflow  began,  and  when  the  patient's  abdomen  was  distended  and 
tense,  the  catheter  was  removed  from  the  appendix,  and  though  no  protection 
against  back-flow  was  taken,  there  was  no  trace  of  leakage,  the  muscular  gut 
and  the  valve  of  Gerlach  proving  competent  to  prevent  any  escape  of  the  lotion. 
After  four  days  the  lotion  was  changed  to  one  of  sodium  bicarbonate  (10  gr.  to 
the  ounce) ,  and  this  was  changed  after  two  days  more  to  one  of  protargol  (4  gr. 
to  I  pint).  The  patient  remained  in  the  hospital  one  month,  and  was  taught 
to  conduct  the  irrigation  himself.  It  was  found  that  after  a  few  days  the  rectal 
tube  was  unnecessary,  the  patient  evacuating  the  lotion  as  soon  as  the  colon 
became  moderately  distended.  He  was  sent  home  ^vith  an  abdominal  plate, 
fitted  with  a  flat,  thin  pad — a  contrivance  found  to  be  unnecessary  in  subse- 
quent cases. 

"  After  two  months  of  self -irrigation  daily  with  6  pints  of  protargol  lotion 
he  was  again  examined  with  the  sigmoidoscope  on  October  29,  1907.  The 
mucous  membrane  was  found  to  be  slightly  inflamed,  and  there  was  still  some 
edema  of  the  submucous  tissue,  but  no  sign  of  ulceration.  The  patient  him- 
self stated  that  he  was  perfectly  comfortable  and  at  work;  he  occupied  himself 
for  half  an  hour  every  morning  with  the  irrigation,  and  after  that  had  no  further 
trouble  during  the  day.  Throughout  his  diet  was  his  usual  one,  and  the  only 
other  treatment  was  the  administration  of  |  gr.  of  calomel  three  times  daily 
while  in  the  hospital."  ' 

^  J.  B.  Dawson,  Brit.  Med.  Jour.,  1909,  i,  78. 


APPENDICOSTOMY  453 

The  time  necessary  to  leave  open  this  fistula  varies  from  one  to  six 
months  in  the  treatment  of  ulcerative  colitis. 

Appendicostomy  may  be  used  instead  of  cecostomy  for  the  relief  of 
abdominal  distention,  as  in  peritonitis  or  malignant  disease.  Thus, 
Dawson  (Joe.  cit.)  reports  a  case  of  Mr.  Keetley's: 

"The  case  was  one  of  carcinoma  of  the  greater  curvature  of  the  stomach, 
involving  the  transverse  colon  and  causing  obstruction  therein.  Appendicos- 
tomy was  performed,  and  a  few  days  later  the  lumen  was  gradually  and  suc- 
cessfully dilated  until  it  admitted  a  No.  4  rectal  tube.  Through  this  the  in- 
testinal contents  drained  well,  the  colon  below  the  obstruction  being  emptied 
by  enemata.  Later  the  gastric  carcinoma  produced  obstruction  of  the  pylorus, 
with  the  usual  signs  of  stenosis  and  dilatation  of  the  stomach.  Jejuncstomy 
was  then  performed,  through  which  the  patient  was  fed.  The  patient  lived 
for  three  and  a  half  months,  being  fed  directly  into  the  jejunum  and  having 
the  bowels  evacuated  through  the  appendix.  Death  ensued,  but  was  unac- 
companied by  the  distress  of  either  gastric  dilatation  or  intestinal  obstruc- 
tion." 

Jacobs  and  Rowlands  mention  a  case  of  volvulus  of  the  cecum, 
operated  on  by  Mr.  Maunsell,  in  which,  after  unfolding  the  volvulus,  he 
performed  appendicostomy,  the  result  being  that  he  effectually  anchored 
the  cecum  and  so  prevented  a  recurrence,  and  also  was  able  to  clear  the 
large  intestine  of  feces  for  the  introduction  of  hot  saline  to  combat 
shock. 

Mr.  Keetley  ^  operated  upon  a  child  aged  a  year  and  ten  months  for 
intussusception  of  the  ileocecal  variety.  After  the  reduction,  he  per- 
formed appendicostomy,  the  advantages  he  claimed  for  the  procedure 
being — (i)  evacuation  of  bowels;  (2)  prevention  of  recurrence;  (3) 
rest  given  to  cecum;    (4)  facility  of  giving  saline  fluid. 

Mr.  Dawson's  further  suggestion  is  quite  worthy  of  consideration: 
"This 'operation  might  be  performed  and  the  opening  utilized  for  feed- 
ing. The  unsatisfactory  results  of  prolonged  rectal  feeding  are  so  well 
known  that  the  suggestion  seems  worthy  of  consideration.  The  opera- 
tion per  se  is  practically  free  from  danger  and  allows  nourishing  fluids  to 
be  passed  into  the  colon,  whence  there  is  considerable  absorption.  It  can 
at  least  be  safely  assumed  that  the  nutriment  taken  into  the  circulation 
would  be  greater  than  in  the  case  of  rectal  enemata.  The  cases  for 
which  such  treatment  would  be  suitable  are  mainly  those  of  ulceration 
or  new-growth  of  the  stomach,  in  which  rest  of  that  viscus  is  indicated." 

*  Brit.  Med.  Jour.,  1905,  ii,  863. 


454  OPERATIONS    ON    THE    ABDOMEN 

APPENDICITIS  AND  ITS  COMPLICATIONS 

It  is  to  be  hoped  that,  as  time  goes  on,  more  men  will  train  themselves 
to  do  appendectomy  ^  through  the  McBurney  ^  incision,  wherein  the 
abdominal  muscles  are  split  rather  than  cut,  making  the  so-called  grid- 
iron opening  between  the  fibers.  The  advantages  of  this  incision  for 
all  types  of  appendicitis,  with  few  exceptions,  have  been  set  forth  in 
several  places  ^  since  McBurney's  original  paper. 

^  It  is  appreciated  that,  etymologically,  append! cectomy  is  the  better  word. 

^  Ann.  Surg.,  xx,  38. 

^  Among  others,  Crandon  and  Scannell,  Boston  Med.  and  Surg.  Jour.,  1905,  cliii,  711. 

"The  muscle-splitting  incision  for  cases  of  acute  appendicitis,  with  abscess  or  without, 
we  wish  to  advocate  and  to  defend,  and,  to  that  end,  we  adduce  the  following  experience 
and  research: 

"  Technique. — The  skin  incision  is  so  made  that  its  middle  is  about  three-quarters  of 
the  distance  from  the, navel  to  the  anterosuperior  spine.  The  incision  is  nearly  transverse — 
that  is,  it  bisects  the  angle  made  by  the  external  and  internal  oblique  muscles  as  they  cross 
each  other. 

"  Fibers  of  the  external  oblique  aponeurosis  are  recognized,  a  nick  is  made  with  the 
knife  between  two  fibers  and  is  enlarged  by  tearing,  either  with  the  knife-handle  or  with 
the  fingers.     This  wound  is  then  held  open  with  retractors. 

"Thick  muscle-fibers  of  the  internal  obhque  are  now  seen  running  nearly  t  right 
angles  to  the  external  obhque.  A  nick  between  fibers,  as  before,  is  followed  by  tearing 
open  of  this  muscle,  as  well  as  the  transversaUs  beneath  it,  and  the  properitoneal  fat  with 
the  two  fingers. 

"After  good  retraction  to  the  full  depths  of  the  wound,  the  peritoneum  is  lifted 
between  two  forceps,  nicked  and  sht  open  transversely  with  blunt  scissors. 

"Closing  the  Wound. — Two  or  three  continuous  catgut  stitches  close  the  peritoneum. 

'■  One  catgut  stitch  holds  together  the  separated  muscle  bundles  of  the  internal  obhque. 

"  One  or,  at  the  most,  two  catgut  mattress  sutures  close  the  external  obhque. 

"  One  or  tv/o  buried  catgut  stitches  hold  together  the  subcutaneous  fat. 

"An  intracutaneous  silkworm-gut  or  horsehair  stitch  closes  the  skin. 

"  Temporary  Drainage. — As  a  precautionary  measure,  certain  early  cases  of  acutely 
inflamed  appendix  require  drainage  for  twenty-four  hours  with  gauze  or  rubber  dam. 
For  this  purpose  the  wound  is  closed  as  before,  except  for  a  passage  large  enough  to  admit 
the  drain  and  in  addition  one  or  two  stitches  of  silkworm  gut  are  put  through  the  skin  and 
external  obhque.  These  stitches  are  left  -ndth  their  ends  tied  together,  and  when  the  drain 
is  removed,  are  tied  tightly  to  close  the  wound. 

"Prolonged  Drainage. — Cases  which  need  drainage  for  several  days  or  longer  need  no 
sutures  unless  the  wound  is  larger  than  need  be  for  the  purpose  of  drainage. 

"Enlarging  the  Wound. — By  enlarging  the  cut  or  spht  in  each  plane  in  either  direc- 
tion, as  seems  necessary,  the  wound  can  be  made  large  enough  for  all  exploration  de- 
sired." 

Should  it  even  be  desired  for  any  reason  to  open  as  far  down  as  the  pehds  it  will  be 
found  that  the  hmit  to  which  the  split  in  the  obhque  muscles  and  the  transversaUs  ap- 
proaches is  the  right  hnea  semilunaris.'  When,  therefore,  in  the  sphtting  process  this  line 
is  reached,  one  may  then  cut  freely  down  the  semilunar  fine,  making  the  whole  incision 
into  a  sort  of  trap-door.  Through  this  a  right  tube  or  an  ovary  can  be  easily  removed, 
and  such  a  wound  is  easily  closed. 

The  Right  Rectus  Incision. — "The  rectus  incision,  so  called,  goes  through  the  skin 
and  anterior  sheath  of  the  right  rectus,  the  muscle-belly  is  retracted  toward  the  median 


APPENDICITIS    AND    ITS    COMPLICATIONS  455 

I.  McBurney  Incision.  No  Drainage. — Tne  intracuticular  stitch 
of  silkworm  gut  or  horsehair  is  tied  over  a  pad  of  gauze  which  rests 
on  the  wound  (Fig.  143).  Outside  of  this  are  a  few  pieces  of  crumpled 
gauze,  held  on  by  zinc-oxid  plaster.  An  excellent  device  to  hold  on 
the  dressing  is  the  zinc-oxid  plaster  straps  and  lacing  (Fig.  144).  A 
swathe  may  be  put  on  for  the  first  t^venty-four  hours  to  keep  the  hand 
of  the  patient  away  from  the  region  until  he  has  fully  recovered  from 
Ijis  ether.  The  single  stitch  is  removed  on  the  eighth  day,  and  all  ten- 
sion is  taken  off  the  incision  by  two  or  three  narrow  straps  of  plaster 
at  right  angles  to  the  incision,  dimpling  it  in.     This  constitutes  the  only 

line  (by  some  operators  the  muscle-belly  is  split),  the  posterior  sheath  is  cut  through,  and 
the  peritoneum  thus  opened. 

"  The  advantages  which  lie  in  this  incision  are  that  it  can  be  made  quickly;  that  it 
allows  indefinite  enlargement  up  or  down;  that  it  is  more  anatomic,  less  destructive,  than 
the  early  method  of  oblique  incision  through  ever}i;hing. 

"  The  disadvantages  of  the  rectus  incision  are,  in  our  opinion,  (i)  That  the  rectus 
muscle  varies  so  much  in  width  in  different  individuals,  that  incisions  intended  to  be  over 
the  muscle-belly  frequently  come  down  directly  on  the  Unea  semilunaris,  making  the  whole 
incision  direct  through  the  abdominal  wall,  with  no  safeguard  against  hernia  in  cases  drained. 
(2)  That  there  is  a  considerable  chance  of  wounding  the  deep  epigastric  vessels,  with  trouble- 
some hemorrhage.  (3)  That,  as  McBurney  says,  the  incision  makes  'an  overhanging 
sheK  under  which  one  is  obliged  to  work.'  (4)  That  this  incision  frequently  opens  into 
clean  abdominal  cavity,  quite  internal  to  the  walled-off  abscess;  that  this  incision  is  internal 
to  the  plane  of  the  mesenteric  origin.  It  will  be  remembered  that  Monks  (Ann.  Surg., 
1905,  xUi,  554)  has  shown  that  the  mesenteric  origin  serves  to  shut  off  the  right  ihac  fossa 
to  some  degree  from  the  rest  of  the  abdominal  cavity,  allowing  the  fossa  to  drain  first  into 
the  pelvis.  Repeated  cases  show  that  the  infection  is  confined  to  the  region  beneath  and 
external  to  the  cecum,  and  we  believe  it  unwarrantable,  therefore,  to  take  the  chance  of 
being  obliged  to  drain  an  abscess  across  a  healthy  gut,  if  such  a  procedure  can  be  avoided. 
(5)  In  cases  drained,  the  skin  tends  to  retract,  leaving  a  broad  area  of  rectus  beUy  to 
granulate  in.  (6)  In  cases  drained  the  chance  of  hernia  in  the  rectus  incision  is  much  greater 
than  in  the  muscle-splitting  incision. 

"  The  Muscle-splitting  Incision. — The  disadvantages  of  this  incision  are  that  it  cannot 
be  made  so  quickly,  that  it  takes  a  certain  amount  of  delicacy  of  dissection  and  care,  par- 
ticularly if  it  is  to  be  enlarged.  (2)  In  cases  of  prolonged  drainage  miuch  more  care  and 
dexterity  is  required  in  replacing  the  wdcks  and  in  maintaining  the  drainage.  This,  we 
believe,  has  been  the  main  ground  for  objection  to  this  incision.  (3)  A  recent  writer 
has  said,  'The  gridiron  incision  should  never  be  used  in  operating  for  an  attack  of  acute 
appendicitis.  As  one  never  can  tell  what  the  condition  of  the  appendix  is,  there  is  danger 
in  an  incision  which  cannot  be  enlarged  without  serious  damage  to  the  parts.' 

"  With  this  we  entirely  disagree. 

"  The  advantages  of  the  muscle-splitting  incision  are:  (i)  That  in  most  cases  it  opens 
directly  over  the  seat  of  the  disease;  (2)  that  it  is  worth  the  care  necessary  to  enlarge  it 
properly,  since  even  after  prolonged  drainage  we  can  practically  assure  the  patient  that  he 
will  have  noTiemia.  From  the  moment  the  patient  leaves  the  operating  table  every  move- 
ment involving  contraction  of  the  abdominal  muscles  tends  to  bring  together  the  splits  in 
these  muscles  and  thus  close  the  gridiron;  (3)  because  of  this  tendency  of  the  wounds  to 
come  together,  stitches  are  of  almost  no  advantage,  and  the  surgeon  is,  therefore,  never 
tempted  to  omit  the  safeguard  of  temporary  drainage  in  doubtful  cases." 


456 


OPERATIONS    ON    THE    ABDOMEN 


dressing  of  such  cases,  and  the  plaster  straps  are  left  on  or  renewed 
until  at  least  three  weeks  from  the  day  of  the  operation. 


Fig.  143.^-AppLYiNG  THE  Dressing  After  Appendectomy. 


The  long  ends  of  the  subcuticular  stitch  of  silkworm  gut  are  tied  together  over  a  folded  sterile  gauze  strip,  and 

the  ends  cut  short. 


It  is  assumed  that  no  wound  is  closed  at  the  end  of  operation  where 
the  appendix  has  showed  on  its  surface  any  well-established  acute 
peritonitis.     Some  surgeons  have  set  the  patient  upright  in  bed  within 


Fig.  144. — Laced  Adhesive  Dressing.  ■  (Devised  by  Ernest  W.  Gushing,  of  Boston,  in  i8g4, 
but  originated  by  D.  Laurentius  Heister,  Venice,  1750,  Vol.  I.,  p.  109.) 

As  used  after  right  rectus  incision. 

a  few  hours  after  operation.  Except  for  purposes  of  drainage  into  the 
pelvis,  as  in  the  Fowler  position  (Fig.  151),  I  see  no  advantages  from  this 
procedure.     Every  patient  is  more  or  less  prostrated  by  the  ether  and 


APPENDICITIS    AND    ITS    COMPLICATIONS 


457 


its  after-effects,  by  the  psychic  effect  of  having  faced  an  operation,  and 
is  more  or  less  uncomfortable  on  account  of  pain  or  morphin.     It  does 


-''m 


Fig.  145. — Removal  of  Perforated  Sheet. 
Hand  holding  the  dressing  in  place. 


not  seem  that  anything  could  be  better  for  the  patient  during  the  first 
day  than  horizontal  rest. 


Fig.  146. — Applying  Adhesive  Plaster  Strips,  Criss-cross,  over  the  Appendix  Dressing. 


The  morning  after  operation,  if  there  is  no  fever,  no  notable  disten- 
tion, and  no  great  amount  of  pain,  the  patient  should  be  set  up  in  bed, 


458  OPERATIONS   ON   THE   ABDOMEN 

and  if  he  stands  this  well,  he  may  get  into  a  chair  in  the  afternoon.  On 
the  second  day  the  forenoon  may  be  spent  in  bed  and  the  time  given 
up  largely  to  the  first  high  enema,  the  movement,  and  the  exhaustion 
following  it.  In  the  afternoon  of  the  second  day  and  thereafter  he  may 
be  up,  and  is  to  be  encouraged  to  move  about  and  become  normal  in  all 
necessary  functions  as  soon  as  possible. 

II.  McBurney  Incision.  Temporary  Drainage. — In  this  division  may 
be  placed  the  cases  where  the  appendix  was  deeply  congested  and 
showed  fibrin  on  its  surface,  or  'presented  any  condition  showing  that 
inflammation  had  penetrated  through  the  walls  of  the  appendix,  and  the 
possibility  exists  that  some  infection  may  have  taken  place  in  the  sur- 
rounding region.  Such  cases  the  conservative  surgeon  drains  tem- 
porarily by  means  of  a  piece  of  rubber  dam  or  a  small  spiral  drain 
(220),  closing  the  wound  by  sutures,  leaving  only  room  enough  for 
for  the  drain  to  emerge.  Through  the  protruding  drain  there  should  be 
put  transversely  a  sterile  safety-pin,  lest  the  drain  slip  into  the  woimd 
during  the  tossing  and  turning  of  the  first  day  after  operation. 

Such  a  temporary  drain  had  best  be  left  in  thirty-six  to  forty-eight 
hours.  If  at  the  end  of  that  time  there  is  no  notable  discharge,  and 
if  the  temperature  is  normal,  or  nearly  normal,  and  has  come  down 
continuously  since  operation,  the  temporary  drain  may  be  pulled  out 
and  a  provisional  suture,  which  was  put  in  and  left  in  with  its  ends 
knotted  at  the  time  of  the  operation,  may  now  be  tied.  If  when  this 
drain  is  pulled  out  there  is  a  little  secretion,  or  if  there  is  the  slightest 
doubt  as  to  the  depth  of  the  wound  being  clean  and  without  pus- 
formation,  the  short  dressing  forceps  may  be  put  into  the  wound  im- 
mediately after  the  drain  is  withdrawn  and  then  allowed  to  open  while 
in  the  wound.  Their  spring  will  separate  the  lips  of  the  wound  a  bit, 
and  into  this  space  may  now  be  poured  a  dram  or  less  of  sterile  glycerin 
or  balsam  of  Peru.  A  small  pad  is  put  over  this  and  the  swathe  or  straps 
applied.  The  use  of  either  of  these  agents  serves  a  four-fold  purpose — 
they  prevent  the  wound  sealing  together  prematurely,  they  are  slightly 
antiseptic,  they  are  stimulative,  and  they  serve  to  shrink  excessive 
granulations. 

If  one  feels  that  there  is  some  noteworthy  infection  in  the  depths  of 
the  wound,  another  small  wick  must  be  inserted  where  the  first  was 
withdrawn,  and  it  may  be  even  considered  wise  to  remove  a  stitch  or  two 
in  order  to  establish  better  drainage. 

III.  McBurney  Incision.  Gangrenous  Appendix  or  Abscess. — In 
these  conditions  the  best  possible  drainage  is  by  means  of  a  spiral  drain 
with  enough  gauze  preferably,  in  my  opinion,  saturated  with  iodoform 


APPENDICITIS    AND    ITS    COMPLICATIONS  459 

10  per  cent.,  protruding,  say,  i  to  2  in.  below  the  end  of  the  rubber,  to 
form  a  certain  amount  of  packing  at  the  bottom  of  the  cavity,  whether 
there  is  a  definitely  localized  abscess  or  whether  the  case  is  one  where 
the  abscess  is  forming;  that  is,  where  the  "chicken-broth"  fluid  or  pus 
is  localized  in  the  lower  right  quadrant.  Such  a  drain,  carefully  placed, 
reaching  to  the  limits  of  the  region  infected  and  in  contact  with  the  ap- 
pendix stump,  may  be  well  left  undisturbed  for  from  t\vo  to  six  days.  It 
is  a  common  procedure  to  "start"  the  wick  on  the  third  or  fourth  day — 
that  is,  to  pull  it  just  clear  of  the  granulations  in  which  it  has  embedded 
itself — to  pull  it  half-way  out  on  the  next  day,  and  to  remove  it  entirely 
on  the  day  following.  If  there  are  no  local  signs,  such  as  tenderness, 
spreading  redness,  bulging  of  the  wound,  exudation  of  pus  round  the 
wick,  or  if  there  are  no  general  symptoms  indicating  lack  of  free  drainage, 
such  as  rising  temperature  or  pulse,  or  abdominal  paresis,  the  wick 
should  be  left  undisturbed  until  the  time  limit  set.  As  long  as  it  remains 
in  place  it  is  exciting  conservative  adhesions — it  is  establishing  in  the 
w^hole  region  one  clean-cut  cavity  without  partitions  and  subcavities,  it 
is  exciting  granulation. 

When  the  first  wick  is  finally  withdrawn  from  such  an  abscess  cavity 
it  usually  must  be  replaced  by  another,  as  the  amount  of  excretion  of  pus 
cannot  be  foretold  in  any  given  case.  Where  wicks  have  to  be  renewed,  and 
closing  in  of  the  abscess  cavity  is  to  be  encouraged,  the  size  of  the  wicks 
should  be  successively  reduced.  In  abscess  cases,  w^here  granulation 
had  already  begun  before  operation,  pus  is  small  in  amount  during 
convalescence,  and  such  a  cavity  may  in  a  few  days  be  filled  with  glycerin 
and  allowed  to  collapse. 

In  cases  where  there  were  a  lot  of  adhesions,  much  fibrin,  or  foul- 
smelling  pus  the  first  wick  will  have  to  be  removed  in  a  short  time, 
perhaps  as  early  as  the  third  day,  and  perhaps  renewed  daily  thereafter. 

Where  there  is  a  definite,  easily  accessible  cavity  to  dress,  wiping  out 
with  a  dry  sponge  often  suffices.  Where  the  cavity  leads  deep  into  the 
pelvis,  and  the  daily  pus  is  considerable  in  amount,  there  are  instances 
where  irrigation  of  the  cavity  with  salt  solution  or  chlorinated  soda 
solution  (1:80),  using  a  slightly  curved  female  catheter  for  irrigating 
nozzle,  will  best  serve  to  clean  the  cavity.  The  danger  cannot  be  over- 
emphasized, however,  if  irrigation  is  used,  that  the  fluid  may  not  flow 
out  of  the  wound  freely  enough,  may  back  up  and  drain  through  adhe- 
sions into  the  general  cavity,  with  serious  results.  Irrigation,  then, 
is  only  for  selected  cases,  and  the  onset  of  the  least  pain  during  its  per- 
formance is  a  signal  to  stop. 

In  case  much  packing  or  several  strips  of  gauze  have  been  necessarily 


460  OPERATIONS    ON    THE    ABDOMEN 

left  in,  their  early  removal  is  extremely  painful  and  may  give  definite 
nervous  shock  to  the  patient  who  is  at  all  sensitive.  Other  things  being 
equal,  the  longer  such  wicks  are  left  in,  within  reason,  the  easier  they 
come  out,  because  of  the  softening  action  of  the  pus  around  them.  When 
such  considerable  amount  of  packing  has  to  be  removed  early,  therefore, 
particularly  if  the  patient  is  one  who  does  not  stand  pain  well, — a  child, 
for  example, — it  is  probably  best,  with  the  help  of  a  safe  anesthetist,  to 
give  a  few  whiffs  of  nitrous  oxid,  ethyl  chlorid,  or  chloroform,  and  pull 
them  out  all  at  once.  If  there  is  good  reason  why  such  an  anesthetic 
should  not  be  given,  the  packing  may  be  got  out  by  starting  the  wicks, 
pulling  an  inch  or  two  out  each  day,  and  cutting  it  off,  or,  if  the  packing 
is  composed  of  several  narrow  strips,  by  pulling  one  out  at  a  time. 

In  the  region  of  a  drained  abscess  there  should  be  for  twenty-four 
hours  practically  no  pain.  If  pain  appears,  it  indicates  lack  of  free 
drainage,  and  the  wicks  should  be  started  or  withdrawn  and  new  smaller 
ones  inserted.  After  this  is  done,  the  application  of  a  hot  salt  and  citrate 
(4  and  1 :  100)  poultice,  or  even  of  the  old-fashioned  flaxseed  poultice, 
may  give  great  comfort  and  aid  free  drainage. 

Some  cases  secrete  an  excessive  amount  of  pus  daily,  and  this  amount 
must  determine  the  frequency  of  the  dressing.  As  a  rule,  once  a  day 
is  enough.  Some  cases,  however,  may  well  be  dressed  every  three  or 
four  hours.  The  "let  alone"  policy  with  regard  to  a  well-placed  wick 
is  the  best.     There  should  be  a  reason  for  every  dressing. 

When  the  temperature  is  practically  down  to  normal,  even  though 
a  considerable  amount  of  suppuration  is  still  present,  the  patient  may 
get  up  if  the  wound  is  well  supported  by  straps  or  swathe.  Getting  the 
patient  partially  or  wholly  up  is  frequently  the  best  stimulant  to  rapid 
convalescence. 

IV.  Right  Rectus  Incision,  Wound  Closed. — These  cases,  after  they 
have  been  sutured  by  layers  and  the  abdomen  is  supported  well  by  zinc- 
oxid  plaster  straps  or  the  laced  straps  (Fig.  141),  call  for  no  treatment 
different  from  a  median  celiotomy.  The  patient  may  sit  up  the  day 
after  operation. 

Right  Rectus  Incision,  Drained. — ^When,  unfortunately,  the  surgeon 
has  to  drain  through  this  incision,  care  should  be  taken  at  the  first  removal 
of  wick  or  packing  not  to  pull  out  a  coil  of  small  intestine,  or  even  to 
bring  such  a  coil  above  the  level  of  the  parietal  abdomen,  for  such  an 
occurrence  makes  ventral  hernia  much  more  likely.  The  wound  should 
be  constantly  supported  by  straps,  and,  as  the  wick  get  smaller,  the 
edges  are  pulled  closer  together  at  each  dressing,  until  ultimately  the 
complete  approximation  of  the  two  granulating  surfaces  is  attained. 


APPENDICITIS    AND   ITS    COMPLICATIONS  461 

Undoubtedly  the  liability  to  hernia^  in  these  cases  is  due  primarily  to 
lack  of  attention  to  just  such  details  in  the  immediate  after-care  of  the 
wound. 

Complications  and  Sequelae. — It  is  trite  enough  to  say  that 
no  t^vo  cases  of  appendicitis  are  alike,  the  possible  postoperative  com- 
phcations  are  so  numerous. 

(i)  General  Peritonitis. — See  pages  151,  418,  421,  458,  459,  and  468. 

(2)  Intestinal  Obstruction. — If  the  abdomen  does  not  distend,  no 
effort  should  be  made  to  move  the  bowels  for  the  first  t\venty-four  to 
thirty-six  hours,  perfect  rest  being  the  ideal  abdominal  condition.  If 
at  any  time,  however,  distention  becomes  notable,  an  effort  should  be 
made  to  get  rid  of  the  gas.  This  distention  may  be  due  to  a  paresis  of 
the  bowel  from  toxemia  or  from  a  peritonitis  of  any  grade.  Until  a 
good  effort  by  means  of  a  well-given  and  searching  enema  has  been 
made,  the  distention  need  cause  no  worry.  Obstruction  may  be  due, 
however,  to  pressure  of  the  packing  or  to  newly  formed  bands  or  adhe- 
sions in  the  region  of  the  appendix.  I  have  seen  several  cases  where 
the  patient  was  not  thoroughly  cleaned  out  before  operation,  in  which 
fecal  impaction  in  the  rectum  was  enough  to  cause  obstruction  after 
operation  because  the  patient  did  not  have  strength  to  force  the  ob- 
structing mass  out. 

(3)  Fecal  Fistula. — This  condition  may  range  from  escape  of  pus  with 
merely  a  fecal  odor,  up  to  the  free  discharge  of  evidently  fecal  material. 
It  may  be  due  to  incomplete  closure  of  the  appendix  stump  by  ligatures; 
to  a  slipping  of  the  appendix  ligature;  to  the  presence  of  a  lost  or  un- 
discovered fecolith  in  the  bottom  of  the  wound;  or  to  a  new  break  in 
the  wall  of  the  cecum  or  ileum,  due  either  to  a  continuation  of  the  gan- 
grenous process  of  the  original  disease,  or  to  the  careless  removal  of  an 
adherent  drainage  wick.     For  treatment,  see  pp.  246  and  421. 

(4)  Stitch  abscess  (see  Chap.  XXIII.,  p.  221). 

(5)  Abscess  in  the  abdominal  ti-all  near  the  region  of  the  wound  may 
appear  in  places  where  the  muscle  layers  have  been  excessively  separated 
during  operation,  or  where  the  drainage  gauze  has  become  dried  and 

1  From  the  Boston  City  Hospital  records  since  1880  we  find  22  hernias.  This  does 
not  represent  all  the  hernias  which  have  occurred,  but  only  those  which  have  come  back 
for  operation. 

Total  hernias  through  appendectomy  scars 22 

Through  old-fashioned  direct  oblique  incision i? 

Through  right  rectus  incision 5 

Through  muscle-splitting  incision o 

These  figures  need  no  comment. 


462 


OPERATIONS   ON   THE   ABDOMEN 


blocks  the  wound.  The  pus  then  burrows  between  the  layers  of  the 
abdominal  wall,  sometimes  extensively.  Careful  burrowing  with  the 
finger  in  the  direction  of  the  tenderness  or  swelling  which  indicates  the 
abscess  should  establish  drainage  and  so  relieve  the  condition. 

V.  Lymphatic  and  Hepatic  Infections.  Subphrenic  Abscess.^ — This 
complication  occurs  approximately  in  i  case  in  1000.  The  abscess 
may  b.e  within  the  peritoneal  cavity  or  in  the  retroperitoneal  tissue.     If 


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Fig.   147. — Acute  Appendicitis   Without 

Drainage. 

Rapid  drop  by  lysis  to  normal. 


Fig.  148. — Acute  Appendicitis. 
Typical  chart;  rise  of  pulse  on  getting  up  and  about. 


intraperitoneal,  the  abscess  may  occupy  only  a  small  portion  of  the 
subphrenic  space,  either  laterally,  or  in  front,  or  behind.  It  may  be 
located  high  up  under  the  dome  of  the  diaphragm.  The  intraperitoneal 
is  far  more  common  after  appendicitis  than  the  extraperitoneal.  The 
infection  travels  along  the  inner  or  outer  side  of  the  colon,  or  toward 
its  anterior  aspect  and  the  abdominal  wall.  Subphrenic  abscess  may 
follow  an  attack  in  ^vhich  there  has  been  no  suppuration  in  or  about  the 

^  See  also  Chapter  IX,  p.  io6  et  seq. 


APPENDICITIS   AND   ITS   COMPLICATIONS 


463 


appendix.  Following  appendicitis  it  is  usually  situated  on  the  right 
side.  It  may  occur  as  a  result  of  a  general  suppurative  peritonitis.  It 
is  sometimes  possible  to  trace  a  suppurative  tract  at  autopsy  from  the 
appendix  to  the  subphrenic  region.  The  complication  follows  not  in- 
frequently in  case  the  appendix  is  retrocecal.  Subphrenic  abscess  may 
rupture  into  the  lung.  It  is  often  complicated  by  pleural  effusion,  the 
presence  of  which  is  explained  by  the  proximity  of  the  subphrenic  space. 


MrE.    S.   H.,    33.    S. 

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Fig.  149. — Acute  Appendicitis  Drained. 

Typical  chart,  irregularities  of  temperature  depending 

on  efficiency  of  drainage  and  on  catharsis. 


Fig.  150. — Appendectomy  after  the  Attack. 

Temperature  on  the  fifth  day  due  to  minute  stitch 

abscess. 


Symptoms. — Persistence  of  high  fever,  rapid  pulse,  and  other  signs 
of  deep-seated  infection,  in  spite  of  thorough  drainage  of  the  primary 
appendix  abscess.  Dulness  corresponding  to  the  left  lobe.  The  ex- 
ploring needle  presents  pus  which  may  be  mistaken  for  an  empyema. 
The  acute  form  may  come  on  in  a  few  days.  It  rpay,  however,  be  sub- 
acute or  chronic.^  The  development  and  symptomatology  of  this  com- 
plication may  be  shown  by  illustrative  cases: 

^  Katz  and  Kendirjy,  Rev.  de  Gyn.  et  de  Chir.  Abdom.,  Paris,  1908,  xii,  469. 


464  OPERATIONS    ON   THE   ABDOMEN 

(i)  Alex  B.  Johnson':  Fourth  day  severe  chill.  Temperature  to  104°. 
During  the  following  forty-eight  hours  physical  signs  and  symptoms  of  sub- 
phrenic abscess  on  the  right  side  developed.  The  ninth  rib  was  resected  and 
the  parietal  and  costal  layers  of  the  pleura  were  sewn  together.  A  large 
amount  of  foul  pus  was  evacuated  from  between  the  liver  and  the  diaphragm. 

(2)  Gangrenous  appendix  with  abscess;  five  weeks  after  the  original 
operation  signs  and  symptoms  of  a  right  subphrenic  abscess  developed. 
Same  treatment  and  recovery.  After  suture  of  the  costal  and  parietal  pleurae 
allow  thirty-six  hours  to  elapse  before  incising  the  diaphragm  unless  at  the 
time  of  operation  the  two  layers  of  pleura  were  infiltrated  and  adherent  to  each 
other,  in  which  instance  an  immediate  incision  is  made.  If  the  diaphragm 
bulges  up  against  the  pleura,  no  air  will  enter  upon  incising  the  costal  layer. 
If,  on  the  other  hand,  the  border  of  a  lung  can  be  seen  moving  freely  up  and 
down,  it  will  be  safer  to  suture  the  two  layers  and  make  incision  through  the 
diaphragm  from  thirty-four  to  thirty-six  hours  later. 

(3)  J.  C.  Munro^  "A  girl  of  eighteen  was  operated  upon  within  twenty-four 
hours  from  the  beginning  of  an  attack  of  acute  appendicitis.  The  gangrenous 
appendix  was  removed,  and  the  wound  was  drained.  There  was  no  infection 
of  the  peritoneum  beyond  the  immediate  region  of  the  appeadix  which  lay 
posterior  to  the  cecum.  The  mesenteriolum  contained  thrombi  and  was 
removed.  For  a  few  days  the  condition  was  satisfactory,  when  the  pulse  and 
temperature  began  to  rise,  and  there  was  slight  icterus,  with  definite  hepatic 
tenderness.  Exploration  of  the  sinus  showed  a  small  abscess  posterior  to 
the  peritoneum  afthe  original  site  of  the  appendix.  Improvement  followed 
drainage  for  a  week,  when  the  symptoms  of  sepsis  again  appeared,  and  three 
weeks  from  the  first  operation  a  pelvic  abscess  not  connected  with  the  first 
wound  was  opened  and  drained.  In  spite  of  free  drainage  the  patient  did 
not  improve,  but  began  to  show  evidence  of  trouble  in  the  upper  abdomen. 
With  more  distinct  signs  as  a  guide,  the  abdomen  was  opened  through  an  epi- 
gastric incision  five  weeks  from  the  time  of  onset,  and  a  foul  subphrenic  ab- 
scess to  the  left  of  the  median  line  was  drained.  The  patient  did  not  improve, 
however,  but  steadily  became  more  and  more  septic  until  death  three  weeks 
later." 

(4)  Munro:  "H.  C.  B.,  male,  aged  thirty-five  years  (Boston  City  Hospital 
Reports,  1902,  146),  had  had  several  attacks  of  severe  abdominal  pain  and 
vomiting  in  the  past  six  or  seven  years.  Each  time  he  had  been  a  little  yellow, 
but  without  chills,  and  the  attacks  lasted  only  a  few  days.  Three  days  before 
entrance  to  the  hospital  he  had  a  sudden,  severe  attack  of  appendicitis,  fol- 
lowed by  sUght  jaundice  and  a  leukocytosis  of  13,000.  He  was  treated  in 
the  medical  wards  for  a  month,  during  which  time  he  had  occasional  chills 
and  high  temperature,  epigastric  pain,  progressive  emaciation,  variable  jaun- 
dice, and  leukocytosis  increasing  steadily  up  to  43,000.     Examination  showed 


^  Ann.  Surg.,  1908,  xhdii,  628. 
^  Ibid.,  1905,  xlii,  692. 


SOBPHRENIC    ABSCESS    AFTER    APPENDICITIS  465 

a  much  emaciated,  jaundiced,  septic-looking  man,  with  an  enlarged  liver, 
especially  on  the  left,  and  doubtful  tenderness  over  the  appendix.  Under 
ether,  the  abdomen  was  opened  in  the  median  line,  above  the  umbilicus. 
One  small,  pinhead  abscess  was  found  on  the  anterior  surface  of  the  right  lobe. 
The  left  lobe  was  uniformly  enlarged,  but  on  the  under  side  there  was  a  deep, 
slightly  indurated  swelling.  This  was  opened  and  a  cavity  containing  pus 
was  found.  Careful  exploration  of  the  right  lobe  failed  to  show  pus.  The 
gall-bladder  and  neighboring  region  were  normal.  The  appendix,  subacutely 
inflamed,  was  removed  through  a  small  opening.  The  patient  was  in  poor 
condition  before  the  operation,  but  on  the  following  day  the  temperature  had 
fallen  to  normal  and  the  pulse  had  fallen  to  120.  There  was  considerable 
discharge  from  the  liver.  Three  days  later  the  temperature  remained  down, 
but  the  pulse  was  rapid  and  weak,  and  he  looked  badly.  Two  days  later  he 
died. 

"Autopsy  showed  between  the  spleen,  stomach,  left  side  of  diaphragm, 
the  liver,  and  posterior  wall  of  the  peritoneal  cavity  an  abscess  containiSng 
offensive,  yellowish,  semifluid  material.  All  the  mesenteric  lymph-nodes 
were  somewhat  enlarged.  One  node  was  softened,  and  contiguous  to  it  was  a 
canal,  that  is,  a  mesenteric  vein,  with  roughened  yellowish  wall  admitting  the 
little  finger  and  communicating  directly  with  the  portal  vein.  On  section 
through  the  left  lobe,  the  portal  veins  v/ere  dilated  and  contained  pus.  In 
the  right  lobe,  particularly  toward  the  superior  surface  and  the  right,  were 
numerous  small  abscesses,  arranged  in  clusters,  3  to  5  cm.  in  diameter." 

The  next  to  the  last  case  illustrates  the  subphrenic  abscess  alone; 
the  last,  both  subphrenic  and  hepatic  infections.  Dr.  Munro  continues : 
"There  must  be  a  considerable  variation  dependent  on  the  individual, 
the  type,  and  the  amount  of  infection  in  the  time  required  for  the  forma- 
tion of  pus  in  appreciable  quantities.  The  clinical  data  on  this  point 
are  very  vague,  but  frequently  there  may  be  a  wide  variation  in  certain 
instances. 

"The  age  at  which  these  infections  take  place  is  limited  mostly  to 
young  adults.  According  to  statistics  of  Musser  and  others,  children 
below  fifteen  are  quite  exempt  from  portal  infections. 

"Diagnosis  of  either  the  lymphangitis  or  the  pylephlebitis  that  is 
secondary  to  appendicitis  is  at  times  impossible.  In  typical  cases  it 
ought  not  to  be  difficult.  We  ought  to  consider  its  probability  in  cases 
exhibiting  sepsis,  jaundice,  hepatic  tenderness. 

"When  the  infection  has  attained  the  subphrenic  space,  the  symp- 
toms are  more  varied,  and  are  frequently  impossible  of  interpretation 
without  exploration  or  operation.  To  quote  freely  from  Griineisen, 
we  must  regard  the  subphrenic  abscess  as  a  circumscribed  peritonitis, 
and  hence  we  often  find  acute,  gradually  increasing  signs  of  peritonitis. 

30 


466  OPERATIONS   ON   THE   ABDOMEN 

At  times  there  is  only  dull  pain.  At  other  times  the  disease  comes  on 
suddenly  with  collapse,  chill,  vomiting,  severe  pain,  etc.  Sometimes 
the  course  is  very  obscure  and  the  picture  of  the  disease  is  not  clear. 
Pain  is  incessant.  In  most  cases  there  is  an  elevation  of  temperature. 
On  examination,  we  often  find  irregular,  marked  arching  in  the  lower 
portion  of  the  thorax  of  the  diseased  side.  This  does  not  behave  in 
respiration  in  a  normal  way.  The  intercostal  spaces  are  obliterated, 
widened,  or  bulged,  and  frequently  painful  on  pressure. 

"Lejars  often  found  a  characteristic  point  of  very  intense  pain. 
The  upper  boundary  of  dulness  often  stands  in  a  convex  line,  and  above 
the  dulness  there  is  found  normal  lung  resonance  in  case  there  is  no 
pleural  effusion.  In  some  cases  one  can  determine  a  marked  change  in 
the  upper  boundary  of  the  dulness  on  inspiration.  The  change  is 
small,  chiefly  because  the  diaphragm  pressed  upward  is  weak  and  lagging. 
If  there  is  gas  in  the  abscess,  there  is  a  clearly  marked  tympanitic  zone 
to  be  recognized,  which  changes  with  the  position  of  the  patient.  One 
finds  characteristically,  from  above  downward,  first,  normal  lung  reso- 
nance, below  this  a  sharply  bounded  tympanitic  zone,  and  then  a  dull 
area  due  to  the  presence  of  the  pus.  This  three-layer  arrangement  in 
zones  can  almost  be  taken  as  pathognomonic.  In  left-sided  abscesses 
the  heart  may  be  pressed  somewhat  upward,  but  not  to  the  right,  while 
in  right-sided  abscesses  the  heart  is  pressed  very  little  toward  the 
left.  The  liver  and  the  stomach  may  be  forced  down  to  a  considerable 
degree. 

"The  determination  of  pus  by  means  of  the  exploratory  needle  is 
an  important  aid  in  the  diagnosis  of  deep-lying  pus-cavities.  Puncture 
is  best  made  in  the  region  of  most  marked  dulness  through  the  ribs 
and  in  the  region  where,  in  case  of  finding  pus,  one  would  eventually 
operate.  One  must  often  make  more  than  one  puncture.  In  one  case 
GriJneisen  reports  36  trials  at  several  sittings."  The  x-ray  may  be  a 
valuable  method  of  locating  these  abscesses. 

To  diagnosticate  a  typical  case  of  portal  phlebitis  should  not  be 
very  difficult.  One  of  Munro's  cases  illustrates  significantly  the  charac- 
teristics of  the  early  stages. 

"T.  S.,  female,  seventeen  years  old.  Ten  days  before  entrance  had  an 
attack  of  sudden  sharp  pain  in  the  region  of  the  umbilicus,  with  vomiting, 
which  continued  for  two  days.  Four  days  before  entrance  she  began  to  have 
dull,  continuous  pain  below  the  costal  margin,  followed  by  chills  and  sweating. 
The  white  count  was  8800.  She  was  in  the  hospital  two  days  before  operation, 
and  grew  distinctly  worse  during  that  time.  There  was  very  slight  jaundice, 
noticeable  only  on  careful  examination;  fullness  through  the  right  hypochon- 


APPENDICITIS    AND    ITS    COMPLICATIONS  467 

drium  into  the  flank,  with  spasm  and  tenderness  over  the  liver.  There  was 
nothing  to  call  attention  to  the  appendix  except  a  distinctly  local  tenderness 
on  deep  pressure  without  spasm. 

"Diagnosis  of  portal  phlebitis  following  appendicitis  was  made,  and  under 
ether  the  abdomen  was  opened  over  the  right  lobe  of  the  liver,  spasm  persisting 
even  under  anesthesia.  On  the  upper  surface  of  the  right  lobe  there  were  three 
or  four  groups  of  small  abscesses.  These  were  incised  and  the  liver  itself 
opened  up  freely  with  the  director  and  finger,  but  no  more  abscesses  could  be 
found.  The  left  lobe  was  normal  in  size.  Various  punctures  were  made  else- 
where in  the  Uver  without  obtaining  any  more  pus.  Through  a  second  ab- 
dominal opening  a  foul  abscess  cavity  surrounding  the  appendix  was  opened 
and  drained.  Two  days  later  the  appendix  wound  was  clean  and  sweet. 
Foul  pus  was  escaping  from  the  liver  and  the  packing  was  removed  without 
hemorrhage.  On  the  fourth  day  after  operation  patient  was  more  or  less 
deUrious,  with  considerable  discharge  from  the  liver,  which  seemed  to  be 
mostly  bile,  and  the  next  day  she  died." 

To  sum  up  the  symptoms:  Jaundice  is  usually  present  in  some 
degree.  Chills  are  apt  to  come  on  early.  Pain  in  the  hypochondrium 
is  characteristic  and  of  diagnostic  importance,  usually  preceding  the 
jaundice  or  accompanying  it.  There  may  be  vomiting  or  diarrhea. 
The  liver  may  be  found  somewhat  enlarged  and  tender,  and  sometimes 
enlargement  of  the  spleen  is  to  be  noted.  The  temperature  is  irregular 
and  frequently  makes  wide  excursions.  The  pulse  is  rapid  and  may 
be  dicrotic.  In  the  acute  forms  there  may  be  somnolence  and  coma, 
or  delirium. 

VI.  Suppuration  in  Other  Distant  Places. — Such  complications  may 
arise  as  a  result  of  a  pyemia  or  suppurative  endocarditis,  either  of  which 
may  complicate  appendix  abscess,  particularly  if  not  efficiently  drained. 
Separate  abscesses  may  appear,  through  the  insufficient  exploration  at 
time  of  operation,  or  due  to  inefficient  after-care  in  respect  to  drainage. 
Collections  of  pus,  for  example,  may  appear  in  the  loin,  about  the 
kidney,  under  the  liver  or  diaphragm,  or  in  the  pelvis.  The  possibility 
of  such  an  occurrence  should  always  be  in  mind.  They  are  sug- 
gested by  persistent  or  rising  fever,  by  pain  here  or  there,  by  the  septic 
fades.  Undrained  pus  in  the  pelvis  will  be  suggested  by  frequency  of 
micturition  or  by  "bearing  jdown"  in  bladder  or  rectum.  Rectal  or 
vaginal  examination  should  establish  the  diagnosis.  Appropriate  opera- 
tive intervention  should  be  made. 

VII.  Empyema  on  the  right  side  has  been  observed,^  due  probably  to 
extension  of  a  subphrenic  abscess. 

*  G.  R.  Fowler^  Treatise  on  Appendicitis,  Phila.,  1894,  62. 


468  OPERATIONS    ON    THE    ABDOMEN 

VIII.  Iliac  or  Femoral  Thrombosis  and  Phlebitis,  Thrombophlebitis. 
— This  complication  is  not  common,  but  seems  frequently  to  appear  in  the 
simple  cases,  where  least  expected.^  It  comes  most  often  between  the 
tenth  and  fourteenth  days  in  debilitated  subjects,^  commonly  in  the  left 
leg,  and  subsides  harmlessly  in  a  few  days.  For  details  of  onset,  course, 
and  treatment,  see  Part  I,  Chapter  IX,  p.  99. 

GENERAL  PERITONITIS 

Many  cases  called  general  peritonitis  are  not  actually  general  in 
extent.  So  true  is  this  that  I  strongly  believe  that  the  surgeon  should 
not,  with  certain  exceptions,  put  his  hand  through  the  infected  peri- 
toneum or  intestines  which  present  in  the  wound,  bathed  in  seropurulent 
fluid  or  pus,  and  then  force  the  hand  in  all  directions  through  the  in- 
testines for  the  mere  purpose  of  finding  out  whether  the  inflammation 
is  general  or  not.  For  the  same  reason  it  seems  to  be  poor  pathology 
and  bad  surgery  to  wash  out  an  inflamed  peritoneum  unless  there  is 
every  sign  that  the  disease  is  truly  general.  In  other  words,  in  many 
cases  an  unwalled  peritonitis  is  kept  local  by  anatomic  structures,  as  in 
the  right  lower  quadrant.^  The  fact  that  there  is  no  wall  of  adhesions 
limiting  a  peritoneal  exudate  does  not  mean  that  the  process  is  generally 
distributed  throughout  the  cavity. 

It  is  assumed,  therefore,  from  the  point  of  view  of  after-treatment, 
that  all  exudation  has  been  sponged  and  wiped  out  with  great  care  and 
thoroughness,  and  that  the  necessary  number  of  drainage-tubes  or  wicks 
have  been  placed  in  one  or  more  incisions  thoroughly  to  drain  the  pelvis 
and  any  other  fossae  which  were  evidently  affected.  In  certain  cases, 
wicks  or  tubes  will  be  put  in  through  an  incision  in  the  vaginal  vault. 

The  patient  is  returned  to  bed  and  placed  in  the  exaggerated  Fowler's 
position*  (Figs.  151-154),  which  directs  the  gravitation  of  all  fluids 
toward  the  pelvis. 

Large  quantities  of  saline  solution  are  to  be  passed  into  the  rectum 
by  the  drop  method.  (See  p.  42.)  A  tube  with  3  or  4  openings  is  intro- 
duced about  4  in.  into  the  rectum.  This  tube  comes  from  a  syringe- 
bag  full  of  salt  solution,  which  feels  somewhat  warm  to  the  hand 
(105°- 110°  F.).  The  bag  is  placed  just  barely  above  the  plane  of  the 
rectum,  and  the  snap  so  placed  on  the  exit  tube  that  the  water  emerges 
from  the  end  about  3  drops  a  second.     The  saline  can  be  absorbed  by 

^  W.  Meyer,  Ann.  Surg.,  1901,  xxxiii,  605. 

^  A.  Sertoli,  Gazz.  degli  Osped.  e.  della  Clin.,  Milan,  1909,  xxx,  121. 
^  G.  H.  Monks,  Ann.  Surg.,  1903,  xxxviii,  574. 

*  This  position  seems  to  be  well  maintained  by  an  adjustable  canvas  chair  devised  by 
Dr.  D.  Tod  Gilliam,  Jour.  Amer.  Med.  Assoc,  1908,  li,  1133. 


GENERAL   PERITONITIS 


469 


the  bowel  at  about  this  rate  (i-^-  pints  per  hour).     By  this  means,  during 
the  first  twenty-four  hours,  6  quarts  may  be  introduced. 


Fig.  151. — Fowler  Position. 
A  pillow  rolled  in  a  sheet  makes  the  bolster. 


FiGi  152. — Fowler  Position. 
Bed  ready:  a  brace  for  the  feet,  a  bolster  for  the  buttocks,  a  comfortable  slope  of  pillows,  the  head  of  the  bed 

elevated  on  tables. 


Food  and  drink  are  withheld  by  mouth  to  limit  peristalsis.  If  hot 
water  is  well  borne,  however,  it  may  be  given.  Enough  morphin  is 
given  only  to  make  life  bearable. 


470 


OPERATIONS   ON   THE   ABDOMEN 


Stimulation  is  to  be  given  as  necessary.  For  excessive  vomiting, 
gavage  is  to  be  practised.  Distention  and  intestinal  paresis  are  to  be 
met  with  the  details  already  given.     (^Chap.  XV,  p.  143.)     Cecostomy, 


Fig.  153. — Fowler  Position. 
As  improvised  in  private  house.     Patient  properly  supported  by  bolster  made  of  a  pillow  rolled  in  a  sheet 
under  the  buttocks.     Feet  braced  against  a  board.     The  angle  of  elevation  of  the  trunk  thus  attained  is  such 
that  all  fluids  gravitate  into  the  pelvis. 

under  cocain  anesthesia,  should  be  resorted  to  without  hesitation  if  it 
offers  the  slightest  possible  advantage. 


Fig.  154. — Inadequate  Fowler  Position. 
Patient,  not  supported,  has  slipped  down  in  bed;  head  and  shoulders  alone  are  elevated.     Bag  for  rectal  saline 

too  high,  its  tube  too  long. 

If  the  wicks  have  been  well  placed,  they  should  not  be  disturbed  for 
many  days.  It  should  be  constantly  remembered  that  after  twenty- 
four  hours  siphon  drainage  stops,  but  that  the  wicks  are  still  valuable  in 
aiding  the  localization  of  diffuse  processes. 


CHAPTER  XL VI 
OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

INCOMPLETE  PERINEORRHAPHY  AND  THE  REPAIR  OF  RECTOCELE^ 

The  external  genitals  are  douched  with  warm  sterile  water  or  salt 
solution  from  a  pitcher  or  doiiche-bag  after  each  movement  of  the 
bowels  and  after  each  urination.  The  labia  majora  are  gently  spread 
by  the  sterile  fingers  of  one  hand  in  order  to  allow  the  entire  perineal 
body  to  be  thoroughly  cleansed.  The  vagina  is  not  entered  and  the  nose 
of  the  pitcher  or  the  douche-tube  is  not  allowed  to  come  in  contact  with 
the  parts.  The  drops  of  fluid  remaining  on  the  genitals  after  the  douche 
are  lightly  absorbed  by  touching  the  tissues  with  dry  gauze,  doing  this 
lightly  several  times  until  all  moisture  has  been  removed.  No  rubbing 
movements  are  employed.  The  perineum  is  dusted  with  a  powder 
consisting  of  equal  parts  of  compound  stearate  of  zinc  and  boric  acid. 
Dry  sterile  gauze  is  then  placed  on  either  side  of  the  stitches,  and  the 
stitches  are  flattened  and  pressed  into  one  of  the  groins  surrounded  by 
the  gauze.  A  tight  T-bandage  is  employed.  In  case  the  bowels  do 
not  move  or  the  urine  is  not  voided,  the  douche  is  given  night  and  morn- 
ing. 

The  patient  is  not  catheterized  unless  she  is  unable  to  pass  her 
urine;  if  necessary,  the  catheter  is  passed  every  eight  hours.  Unless 
extremely  uncomfortable,  the  patient  is  allowed  to  go  for  the  first  eigh- 
teen to  twenty-four  hours  after  operation  before  resorting  to  the  use  of 
the  catheter. 

The  bowels  are  kept  free  by  the  administration  of  one  or  t^vo  tea- 
spoonfuls  of  compound  licorice  powder  night  and  morning,  beginning 
on  the  morning  following  the  day  of  operation.  In  case  the  bowels  do 
not  move  daily  by  means  of  the  licorice  powder  an  enema  should  be 
given  in  order  to  secure  a  daily  evacuation,  taking  care  to  pass  the  rectal 
nozzle  along  the  posterior  wall  of  the  rectum.  Soft-solid  nourishment 
is  given  until  the  bowels  move,  and  then  full  diet  is  allowed. 

The  patient  is  allowed  to  lie  in  any  position,  but  should  not  be  per- 
mitted to  turn  herself.     Tying  the  legs  together  and  placing  a  pillow 

^  An  operation  for  the  repair  of  a  rectocele  always  includes  perineorrhaphy. 

471 


472 


OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 


beneath  the  knees  are  unnecessary,  unless  they  add  to  the  comfort  of  the 
patient.     When  upon  her  side,  the  back  should  always  be  supported  by 


Fig.  iss- — Vaginal  Dressing  Set. 


a  pillow  crowded  in  behind  it,  in  order  to  diminish  any  tension  on  the 
stitches  from  the  weight  of  the  body. 

The  stitches  are  removed  in  ten  to  fourteen  days.     The  patient  is 
allowed  to  sit  up  in  bed  with  a  head-rest  on  the  fourteenth  day  and  to 


Fig.  156. — Vaginal  Douche. 
Patient  in  position. 


get  up  out  of  bed  on  the  seventeenth  day.     She  can  walk  about  on  the 
eighteenth  day. 


INCOMPLETE    PERINEORRHAPHY    AND    THE    REPAIR    OF   RECTOCELE     473 

Complete  Perineorrhaphy. — The  after-treatment,  as  already 
described  for  incomplete  lacerations  of  the  perineum,  is  carried  out  with 
certain  additions  and  modifications. 

The  bowels  should  be  moved  the  next  day  after  the  operation  in 
the  following  way:  On  the  morning  after  the  day  of  operation  an  ounce 
of  castor  oil  should  be  given  by  mouth ;  twelve  hours  later  an  oil  enema, 
consisting  of  8  oz.  of  warm  sweet  oil,  should  be  given  by  means  of  a 
rectal  syringe.  If  the  surgeon  has  any  doubt  about  the  ability  and 
experience  of  the  nurse,  he  should  give  the  enema  himself.  The  syringe- 
tip  must  be  passed  with  extreme  care  into  the  posterior  part  of  the  anal 
opening,  and  then  very  gently  along  the  posterior  wall  of  the  bowel 
to  avoid  the  rectal  sutures.  The  oil  should  be  introduced  slowly,  and 
then  the  syringe  must  be  withdrawn  with  the  same  caution  which  was 


Fig.  157. — Vaginal  Douche. 
Introducing  the  nozzle. 


used  in  its  introduction.  The  patient  is  instructed  to  allow  the  move- 
ment to  occur  gradually  and  to  make  no  straining  efforts.  It  may  be 
necessary  for  her  to  remain  upon  the  bed-pan  for  an  hour  or  even  longer 
before  an  evacuation  occurs.  In  case  the  desire  to  move  the  bowels  is 
felt  after  receiving  the  castor  oil,  before  the  enema  has  been  given, 
then  the  enema  should  be  given  at  once.  After  this  the  bowels  must 
be  kept  freely  open  by  licorice  powder,  given  in  doses  of  i  or  2  teaspoon- 
fuls  morning  and  night.  No  straining  at  stool  is  exer  permissible,  and 
if  at  any  time  the  patient  experiences  difficulty  in  defecation  during  the 
first  two  weeks  following  operation,  an  oil  enema  must  be  given  with  the 
precautions  above  described. 

A  liquid  diet  without  milk  is  given  until  the  bowels  move.     After 
the  bowels  move,  a  soft-solid  diet  is  allowed,  but  milk  is  restricted  to 


474  OPERATIONS    ON   THE    VAGINA,    UTERUS,    AND    ADNEXA 

a  minimum  because  of  the  character  of  the  residue  which  it  leaves  in 
the  feces. 

The  stitches  are  removed  on  the  fourteenth  day.  The  patient  is 
allowed  to  sit  up  in  bed  with  a  head-rest  on  the  twenty-first  day  and  to 
get  up  out  of  bed  on  the  hventy-fourth  day.  She  can  walk  about  on 
the  t^venty-fifth  day. 

The  Repair  of  Cystocele. — No  irrigations  are  necessary  after 
a  cystocele  operation,  in  the  absence  of  a  vaginal  discharge,  beyond  a 
careful  cleansing  of  the  external  genitals  with  a  sterile  fluid  after  each 
movement  of  the  bowels  and  urination.  In  the  presence  of  a  vaginal 
discharge,  however,  a  vaginal  douche  should  be  carried  out  every  twelve 
hours  in  the  following  manner:  A  glass  vaginal  douche-tube  is  passed 
carefully  for  its  entire  length  over  the  perineal  body,  hugging  it  tightly, 
the  irrigating  fluid  being  allowed  to  flow  during  the  introduction.  In 
the  removal  the  precaution  is  likewise  observed  to  keep  the  nozzle 
in  close  approximation  with  the  perineal  body.  In  the  event  of  a 
vaginal  discharge,  after  the  combined  operation  for  cystocele  and  lacera- 
tion of  the  perineum,  the  douche-tube  must  be  passed  with  great  caution 
along  the  middle  of  the  introitus  vaginse,  at  a  point  equidistant  from 
its  anterior  and  posterior  angles.  Such  a  vaginal  douche  should  precede 
the  irrigation  of  the  perineum. 

The  patient  should  be  placed  upon  the  bed-pan  three  hours  after 
the  operation,  and  then  be  given  the  bed-pan  every  three  hours  in  the 
hope  that  she  may  pass  her  urine.  But  this  she  is  rarely  able  to  do. 
The  bladder  should  not  be'  allowed  to  become  distended.  It  is  seldom 
possible  for  the  patient  to  go  more  than  nine  to  twelve  hours  without 
the  occurrence  of  painful  distention,  and  after  this  operation  the  catheter 
should  not  be  withheld  more  than  six  hours.  Catheterization,  if  neces- 
sary, should  be  carried  out  once  in  four  hours  for  three  days,  then  once 
in  six  hours  for  three  days,  and  then  once  in  eight  hours  until  the  patient 
can  be  induced  to  urinate  spontaneously.  Before  resorting  to  the  use 
of  the  catheter,  after  any  gynecologic  procedure,  persistent  efforts  should 
be  carried  out  to  encourage  the  patient  to  pass  her  urine  herself — i.  e., 
by  hot  compresses  to  the  abdomen,  thighs,  and  vulva,  pressure  over 
the  bladder,  trickling  of  sterile  water  over  the  introitus,  the  production 
of  the  sound  of  running  water  in  the  room,  and  lying  on  the  face.  Oc- 
casionally a  hot  enema  may  have  the  desired  effect. 

The  bowels  are  kept  free  by  compound  licorice  powder  and  enemas 
as  above  described. 

Soft-solid  diet  is  advisable  until  the  bowels  move,  and  then  a  full 
diet  may  be  allowed.     During  the  entire  convalescence  it  is  well  for 


VESICOVAGINAL    FISTULA  475 

the  patient  to  drink  water  copiously.  In  the  event  of  the  complication 
of  vesical  irritation  supervening  in  the  convalescence  the  patient  should 
be  given  cystogen,  5  gr.  three  times  daily,  and  large  quantities  of 
cream  of  tartar  water  should  be  administered. 

As  the  stitches  are  entirely  of  catgut,  it  is  unnecessary  to  remove  them. 
The  patient  is  allowed  to  sit  up  in  bed  with  a  head-rest  on  the  fourteenth 
day  and  to  get  out  of  bed  on  the  seventeenth  day.  She  may  w^alk  about 
on  the  eighteenth  day. 

References 

T.  A.  Emmet,  A  Study  of  the  Etiology  of  Perineal  Laceration  -uith  a  New  Method 
for  Its  Proper  Repair,  Trans.  Amer.  Gyn.  Soc,  1883,  viii,  198. 

C.  P.  Noble,  Kelly-Noble,  Gynecology  and  Abdominal  Surgery,  1907,  i,  350. 

E.  McDonald,  Lacerations  of  the  Perineum,  Surg.,  Gyn.  and  Obst.,  1908,  \'i,  47. 

T.  J.  Watkins,  The  Operative  Treatment  of  Cases  of  Extensive  Cystocele  and  L'terine 
Prolapse,  Surg.,  Gyn.  and  Obst.,  1909,  \'iii,  47. 

VESICOVAGINAL  FISTULA 

The  after-treatment  of  a  vesicovaginal  fistula  is  of  the  greatest  im- 
portance in  determining  the  success  of  the  operation.  Constant  drainage 
is  maintained  by  a  self-retaining  catheter,  which  is  removed,  cleaned, 
boiled,  and  replaced  twice  daily.  Each  time  that  the  catheter  is  replaced 
the  bladder  is  irrigated  w  ith  warm  4  per  cent,  boric-acid  solution,  allow- 
ing not  more  than  4  ounces  to  enter  the  bladder  at  once,  so  avoiding 
undue  pressure  upon  the  stitches.  Once  each  day  the  patient  is  placed 
in  the  Sims  posture,  the  posterior  vaginal  wall  being  retracted  by  a 
Sims  speculum,  and  the  stitches  are  gently  irrigated  with  sterile  water. 
The  anterior  wall  is  then  gently  wiped,  or,  better,  patted  dry,  using 
sterile  absorbent  cotton  in  preference  to  gauze  because  of  its  softer 
texture,  and  then  carefully  powdered  with  equal  parts  of  compound 
stearate  of  zinc  and  boric  acid.  The  vulva  is  covered  with  a  sterile  pad. 
Constant  drainage  is  continued  until  the  tenth  day.  The  stitches  are 
removed  on  the  fourteenth  day,  most  conveniently  with  the  patient  in 
the  Sims  posture. 

The  patient  may  sit  up  in  bed  after  the  stitches  are  removed  and  get 
out  of  bed  on  the  fifteenth  day. 

The  bowels  are  moved  by  a  suds  enema  the  morning  after  operation, 
and  are  then  kept  open  by  extract  cascara  sagrada,  lo  gr.,  or  some 
other  laxative,  at  night,  an  enema  being  given  whenever  the  bowels  do 
not  move  freely  with  cathartics.  After  each  movement  the  perineum 
should  be  irrigated  with  sterile  water,  care  being  taken  that  none  of  the 
fluid  enters  the  vagina,  and  the  vulva  is  covered  with  a  fresh  sterile 
pad. 


476      OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

Water  is  given  as  soon  as  the  patient  is  out  of  ether.  By  afternoon 
of  the  same  day  the  patient  is  able  to  take  light  nourishment — some  form 
of  broth  with  crackers  or  toast,  and  the  following  morning  may  resume 
her  usual  diet. 

Hexamethylamin,  lo  gr.  three  times  a  day,  as  a  prophylactic  against 
cystitis,  may  be  given  during  the  first  ten  days.  Twenty  grains  of 
potassium  acetate  may  be  given  with  each  dose,  and  the  patient  should 
drink  2  quarts  of  cream  of  tartar  lemonade  (see  p.  511)  daily  between 
meals,  in  this  way  promoting  a  continuous  irrigation  of  the  bladder 
with  a  dilute,  non-irritating  fluid. 

References 
J.   Marion  Sims,    On  the  Treatment  of  Vesicovaginal  Fistula,  Amer.  Jour.  Med. 
Sci.,  1852,  xxiii,  59. 

T.  A.  Emmet,  Vesicovaginal  Fistula,  N.  Y.,  1868. 
H.  A.  Kelly,  Operative  Gynecology,  1906,  i,  425. 

RECTOVAGINAL  FISTULA 

The  operation  for  this  condition  should  not  be  undertaken  until  the 
bowel  has  been  thoroughly  cleaned  out  and  the  vagina  rendered  as  clean 
as  possible,  otherwise  the  most  careful  after-treatment  may  not  be  able 
to  avert  failure. 

The  vagina  is  irrigated  t\vice  daily  with  sterile  water,  keeping  the 
douche-nozzle  as  close  to  the  anterior  wall  as  possible.  The  vulva  is 
covered  with  a  sterile  pad.     The  stitches  are  removed  on  the  tenth  day. 

The  bowels  must  be  kept  loose  and  the  intestinal  contents  soft 
from  the  beginning.  All  enemas  are  to  be  avoided.  The  morning  of 
operation  the  patient  is  given  i  ounce  of  Epsom  salt.  This  is  repeated 
the  following  morning,  and  thereafter  ^  ounce  is  given  every  morning  for 
ten  days.  After  the  tenth  day,  the  bowels  must  be  kept  loose,  but  some 
other  cathartic,  such  as  cascara  or  the  compound  cathartic  pill,  may  be 
employed. 

The  diet  must  be  liquid,  without  milk,  from  four  days  before  opera- 
tion to  the  tenth  day.  From  the  tenth  to  the  fourteenth  day  a  soft- 
solid  diet  may  be  taken,  and,  beginning  with  the  fifteenth  day,  full  diet 
may  be  resumed. 

The  patient  may  sit  up  after  the  stitches  are  removed  and  get  out  of 
bed  on  the  twelfth  day. 

EXCISION  OF  THE  VULVA 

Excision  of  parts  of  the  vulva  may  be  indicated  for  malignant  disease 
— elephantiasis,  pruritus,  kraurosis,  or  tuberculosis.     It  is,  as  a  rule, 


VULVOVAGINAL   ABSCESS  477 

possible  to  close  the  incision  with  silkworm-gut  sutures.  Owing  to  the 
impossibility  of  preventing  the  urine  and  feces  from  soiling  the  dressing 
the  parts  should  simply  be  kept  clean  and  dry,  and  covered  with  a  sterile 
pad.  After  each  defecation  or  micturition  the  wound  should  be  irrigated 
with  sterile  water,  and  dusted  with  compound  stearate  of  zinc  and  boric 
acid,  equal  parts.  The  patient  should  be  kept  in  bed  until  the  stitches 
are  removed  on  the  seventh  day.  Diet  need  not  vary  from  that 
ordinarily  taken  by  the  patient. 

EXCISION  OF  URETHRAL  CARUNCLE 

Outside  of  rendering  the  urine  dilute  and  non-irritating,  this  opera- 
tion requires  no  special  after-treatment.  The  patient  should  take 
20  gr.  of  potassium  acetate  three  times  daily,  and  should  be  instructed 
to  drink  10  glasses  of  water  daily. 

Hemorrhage  occasionally  occurs,  and  will  be  controlled  by  a  No.  oo 
catgut  stitch  in  the  mucous  membrane.  This  may  be  taken  with  the 
variety  of  needle  designed  for  the  repair  of  a  vesicovaginal  fistula,  under 
cocain  anesthesia,  obtained  by  placing  a  crystal  of  cocain  hydrochlorid 
in  the  urethra  and  allowing  it  to  dissolve. 

VULVOVAGINAL  ABSCESS 

The  abscess  should  always  be  opened  upon  the  inner  surface  of  the 
labium.  The  abscess  cavity  is  tightly  packed  with  sterile  gauze  and 
the  vulva  is  covered  with  a  sterile  pad.  The  packing  is  removed  the 
following  day.  This  may  be  done  either  in  the  Sims  or  dorsal  posture. 
After  the  packing  is  out,  the  vulva  should  be  washed  off  four  or  five 
times  daily  with  an  antiseptic  solution.  The  patient  is  to  wear  a  pad 
as  long  as  there  is  any  discharge.  She  may  get  up  as  soon  as  she  is 
completely  out  of  ether.  When  the  tenderness  about  the  labium  has 
subsided,  treatment  of  the  gonorrhea  should  be  continued  or  instituted. 

In  the  rare  cases  in  which  a  vulvovaginal  abscess  is  successfully  dis- 
sected out  without  rupture,  the  incision  should  be  closed  with  silkworm 
gut.  The  stitches  are  washed  off  after  each  micturition  or  dejection, 
and  the  vulva  kept  covered  with  a  sterile  pad.  The  patient  may  get  up 
the  next  morning,  but  should  remain  in  her  room  until  the  stitches  are 
taken  out  on  the  seventh  day.- 

Hemorrhage  is  the  one  complication  to  be  looked  for.  If  it  occurs 
after  an  abscess  has  been  incised,  it  is  treated  by  a  larger  and  firmer 
packing.  When  it  occurs  after  an  abscess  has  been  dissected  out,  it 
may  give  rise  to  a  large  hematoma  in  the  labium.  A  moderate  amount 
of  ecchymosis  always  occurs  after  this  operation,  and  may  usually  be 


478      OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

disregarded,  but  if  the  whole  labium  becomes  swollen  and  tender,  the 
stitches  must  be  removed,  the  clot  evacuated,  and  the  cavity  packed 
for  twenty-four  hours. 

CYST  OF  BARTHOLIN'S  GLAND 

All  that  has  been  said  concerning  the  dissection  of  a  vulvovaginal 
abscess  applies  to  the  removal  of  a  cyst. 

VAGINAL  SECTION  (COLPOTOMY)  FOR  DRAINAGE  OF  PELVIC 

ABSCESS 

The  pus-cavity  is  firmly  packed  with  a  large  strip  of  sterile  gauze, 
or,  if  there  are  two  distinct  cavities,  a  separate  packing  is  passed  into 
each.  The  vagina  is  also  packed,  and  the  vulva  covered  with  a  sterile 
pad.  The  patient  is  put  to  bed  in  Fowler's  position.  At  the  end  of 
forty-eight  hours,  or  sooner  if  there  is  a  marked  rise  of  temperature, 
the  packing  is  removed  under  primary  anesthesia  and  replaced  by  a  sterile 
gauze  wick  or  a  wick  to  each  pus-cavity  if  there  are  two.  No  packing 
is  now  needed  in  the  vagina.  The  dressing  is  changed  every  other  day. 
After  the  seventh  day  the  sinus  may  be  irrigated  with  i :  800  chlorinated 
soda  solution  at  each  dressing.  The  sinus  is  drained  by  wicks  until  it 
has  closed  in  2  in.  in  depth,  and  the  temperature  is  normal.  The 
Fowler  position  is  maintained  forty-eight  hours. 

The  patient  is  given  water  as  soon  as  out  of  ether.  Liquid  diet  is 
started  the  next  morning,  soft  solids  the  second  day,  and  full  diet  the 
fifth. 

The  bowels  are  opened  by  calomel  the  night  after  operation,  fol- 
lowed by  an  enema  the  next  morning. 

The  patient  may  sit  up  in  bed  at  the  end  of  a  week  if  the  temperature 
is  normal,  and  may  get  up  after  the  wicks  are  left  out. 

Complications  and  Sequelae. — Backing  Up  or  Faulty  Drainage. 
— This  is  the  most  common  complication.  It  is  manifested  by  a  sudden 
or  steady  rise  in  the  temperature,  often  accompanied  by  a  chill  and 
vomiting,  usually  by  abdominal  pain.  There  is  some  tenderness,  occa- 
sionally some  spasm,  and  sometimes  a  palpable  mass  in  the  lower  ab- 
domen. The  patient  is  given  primary  ether,  and  two  fingers  introduced 
into  the  sinus,  which  is  dilated  until  the  pocket  of  pus  is  felt  as  a  round, 
fluctuant  mass,  which  is  then  broken  into  and  evacuated.  Then  other 
pockets  are  searched  for,  and  the  whole  sinus  thoroughly  dilated  and 
packed.  After  this  the  patient  should  be  treated  as  though  she  had 
undergone  a  second  vaginal  section. 

Peritonitis. — If,  after  a  vaginal  section,  the  temperature  and  pulse 


VAGINAL    SECTION    FOR    DRAINAGE    OF    PELVIC    ABSCESS  479 

rise  rapidly,  the  abdomen  becomes  distended,  more  tender  and  more 
rigid,  and  vomiting  increases,  the  development  of  peritonitis  may  be 
suspected.  In  such  an  instance  the  patient  is  given  primary  ether, 
the  packing  withdrawn,  and  the  cavity  explored.  If  communication  is 
found  with  the  peritoneum,  it  should  be  carefully  enlarged  and  a  rubber 
drainage-tube  passed  into  the  peritoneal  cavity.  If  a  large  enough  tube 
or  a  double  tube  is  used,  little  difificulty  will  be  experienced  in  keeping 
it  in  place.  This  tube  may  be  left  in  situ  for  four  or  five  days  unless 
it  becomes  clogged  or  slips  out,  in  which  case  it  should  be  cleaned  and 
replaced.  The  patient  should  now  be  treated  exactly  as  after  a  celi- 
otomy for  general  peritonitis — high  Fowler  position,  continuous  rectal 
saline,  etc. 

The  greatest  difficulty  lies  here  in  the  diagnosis  of  beginning  peri- 
tonitis, for  after  all  vaginal  sections  there  is  some  reaction,  characterized 
by  a  higher  temperature  for  twelve  to  twenty-four  hours,  with  consider- 
able tenderness  and  spasm.  The  rise  in  pulse-rate,  combined  with 
abdominal  distention  and  persistent  vomiting,  are  the  most  important 
aids  in  the  diagnosis.  Under  no  circumstances  should  the  abdomen  he 
opened,  for  we  have  in  the  vaginal  opening  the  best  possible  mechanical 
provision  for  drainage.  Furthermore,  in  the  large  majority  of  cases 
we  shall  be  dealing  with  a  somewhat  localized  pelvic  peritonitis,  and  to 
open  the  abdomen  may  result  in  breaking  down  some  of  the  walling  off 
and  scatter  the  process  throughout  the  abdomen.  If  the  patient  will 
not  recover  on  vaginal,  she  will  not  on  abdominal,  drainage. 

Hemorrhage. — Hemorrhage  is  seldom  sufficient  to  give  trouble. 
The  only  treatment  is  to  remove  all  the  gauze  from  the  abscess  cavity 
and  repack  firmly,  with  a  firm  vaginal  pack  in. addition. 

Injury  to  the  Rectum. — This  is  more  likely  to  occur  in  opening  small 
than  large  abscesses.  The  diagnosis  will  not  be  made  until  the  first 
dressing,  when  the  fecal  odor  will  be  detected  on  the  packing.  All 
packing  must  be  omitted  and  the  vagina  kept  clean  by  sponging  twice 
a  day  with  chlorinated  soda  solution  (i :  800)  until  the  fifth  day,  after 
which  douches  of  the  same  solution  are  given  twice  daily.  An  enema 
of  salt  solution  is  given  every  day,  and  the  bowels  are  kept  moving  from 
above  by  catharsis.     Spontaneous  closure  is  the  invariable  result. 

After  this  operation  there  remains  for  a  considerable  time  a  great 
deal  of  induration  throughout  the  pelvis  and  a  more  or  less  profuse 
vaginal  discharge.  For  the  double  purpose  of  depletion  and  cleanliness 
the  patient  should  take  hot  i :  800  chlorinated  soda  douches  in  the 
recumbent  position,  with  the  hips  elevated,  twice  a  day.  Depletion 
with  a  glycerin  tampon  three  times  a  week  should  also  be  practised. 


480     OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

In  many  cases  a  symptomatic  cure  will  be  effected  even  though  traces 

of  the  inflammation  remain  on  pelvic  examination.     In  others,  sooner 

or  later,  symptoms  return  and  celiotomy  will  then  have  to  be  done.     It 

must  always  be  remembered  that  vaginal  section  has  its  chief  usefulness 

as  a  life-saving  operation  in  cases  of  pelvic  abscess  where  celiotomy 

and  removal  of  the  appendages  would  be  extremely  dangerous,  and 

makes  possible  the  removal  of  the  source  of  trouble  later,  when  it  can 

be  done  with  little  risk. 

References 

A.  T.  Cabot,  Treatment  of  Pelvic  Abscess,  Amer.  Gyn.  and  Ped.,  1892,  v,  540. 
E.  B.  Young,  An  Analysis  of  Twenty-one  Cases  of  Pelvic  Abscess  Treated  by  Vaginal 
Section,  Boston  Med.  and  Surg.  Jour.,  1907,  clvi,  76. 

VAGINAL  SECTION  FOR  REMOVAL  OF  THE  APPENDAGES 

This  is  done  in  preference  to  celiotomy  by  some  surgeons.  The 
after-treatment  does  not  vary  from  that  after  vaginal  section  for  pelvic 
abscess,  except  in  the  dressings  and  in  the  greater  rapidity  of  conval- 
escence. If  the  appendages  have  contained  pus,  the  dressing  is  identical. 
After  the  removal  of  an  extra-uterine  pregnancy,  of  ovarian  cysts,  or 
chronically  inflamed  tubes,  the  vaginal  vault  is  sewed  up  except  for  a 
short  space  through  w^hich  is  inserted  a  small  gauze  drain.  The  vagina 
is  lightly  packed  with  sterile  gauze.  This  wick  and  the  vaginal  gauze 
are  changed  on  the  second  day  and  removed  for  good  on  the  fourth  day, 
except  in  case  of  an  extra-uterine  with  rupture,  or  tubal  abortion  into 
a  walled-off  cavity,  in  which  event  the  drainage  is  maintained  until  the 
cavity  closes  down,  the  wick  being  changed  every  other  day.  Fowler's 
position  is  maintained  until  after  the  second  dressing. 

The  patient  may  sit  up  on  the  seventh  and  get  out  of  bed  on  the 
tenth  day. 

Complications  and  Sequelae. — Injury  to  the  rectum  and  peri- 
tonitis are  rare.  The  treatment  is  the  same  as  described  under  vaginal 
section  for  pelvic  abscess. 

Hemorrhage  is  more  common  than  after  pelvic  abscess,  and  is  to  be 
treated  by  drawing  the  stump  of  the  amputated  appendages  down 
through  the  vaginal  opening  by  means  of  volsella  or  double  hooks,  and 
picking  up  the  bleeding  point,  which  is  then  ligated  if  possible,  or  if 
not,  the  clamp  is  left  on  for  forty-eight  hours. 

References 

W.  H.  Baker,  Vaginal  Ovariotomy,  N.  Y.  Med.  Jour.,  1882,  xxv,  250. 

W.  R.  Pryor,  The  Treatment  of  Adherent  Retroposed  Uteri,  Trans.  Amer.  Gyn.  Soc, 


VAGINAL    HYSTERECTOMY 


481 


VAGINAL  HYSTERECTOMY 
Diessing". — Ligature  Method. — At  the  completion  of  the  opera- 
tion, a  gauze  wick  is  passed  up  into  the  pelvis  through  an  opening 
which  is  left  in  the  vaginal  vault,  and  the  vagina  packed  firmly  with 
sterile  gauze.  The  vulva  is  covered  with  a  sterile  pad  held  by  a  T 
bandage.  The  patient  is  put  to  bed  in  Fowler's  position.  Unless  there 
is  a  sudden  or  marked  rise  in  temperature,  this  dressing  is  left  undis- 
turbed until  the  fourth  day,  when  it  is  removed  and  replaced.  The 
dressing  is  now  changed  every  other  day,  the  size  of  the  wick  being 
decreased  as  the  sinus  closes  down,  and  as  soon  as  the  sinus  ceases  to 
discharge,  the  wick  is  omitted  entirely.  The  Fowler  position  is  main- 
tained until  after  the  second  dressing,  or  longer  if  there  is  profuse  dis- 
charge from  the  sinus.  No  irrigation  is  permissible  before  the  eighth 
day. 


Fig.  158. — Vaginal  Hysterectomy.    Clamp  Method.   - 
Clamps  held  apart  and  in  place  by  gauze. 

Clamp  Method. — At  the  end  of  the  operation  a  firm  gauze  packing 
is  carried  up  into  the  pelvis  through  the  opening  in  the  vaginal  vault, 
and  the  vagina  packed  in  such  manner  that  each  clamp  is  separated 
from  the  others  by  gauze.  The  handles  of  the  clamps  are  all  tied  to- 
gether outside  the  vulva,  and  gauze  wound  between  and  round  them 
(Fig.  158).  They  are  then  covered  over  with  a  large  pad,  wrung  out 
in  some  antiseptic  soludon,  and  outside  of  the  w^hole  a  piece  of  oiled 
■silk  is  tied  on.  The  oiled  silk  and  the  antiseptic  pad  are  changed  after 
each  evacuation  of  the  bowels  or  bladder.  The  clamps  are  removed 
under  priniary  anesthesia  at  the  end  of  forty-eight  hours,  the  sinus 
rewicked,  and  the  vagina  packed.  The  treatment  from  this  point  does 
not  differ  from  that  after  the  ligature  method,  except  that  convalescence 
is  slower  and  less  satisfactory. 

31 


482  OPERATIONS   ON   THE    VAGINA,    UTERUS,    AND   ADNEXA 

Stay  in  Bed. — The  patient  may  sit  up  in  bed  on  the  twelfth  and 
get  out  on  the  fourteenth  day. 

Bowels. — The  bowels  should  be  moved  by  3  gr  of  calomel  in 
divided  doses  the  night  following  operation  and  an  enema  the  next 
morning.  They  should  then  be  kept  open  by  daily  catharsis,  compound 
cathartic  pills  being  a  satisfactory  agent. 

Diet. — As  soon  as  the  patient  is  out  of  ether  hot  water,  and  shortly 
cold  water,  may  be  given  her.  Early  the  next  morning  she  is  started 
on  hot  broths.  As  soon  as  she  is  absolutely  free  from  nausea,  generally 
by  the  morning  of  the  second  day,  or,  W'here  the  clamp  method  has 
been  employed,  the  third  day,  soft-solid  diet  may  be  begun.  Chicken 
is  added  on  the  fourth  day  and  full  diet  is  begun  on  the  fifth. 

Bladder. — The  patient  should  be  catheterized  before  the  dressing 
is  introduced  at  the  end  of  the  operation,  and  if  bloody  urine  is  found, 
an  injury  to  the  bladder  should  be  searched  for  and  repaired.  In 
this  event  a  self-retaining  catheter  is  kept  in  the  bladder  during  the  first 
ten  days,  being  removed,  cleaned,  boiled,  and  the  bladder  irrigated 
twice  a  day.  Where  there  has  been  no  injury  to  the  bladder,  the  patient 
may  be  allowed  to  go  until  the  bladder  begins  to  be  distended  if  unable 
to  void  urine  herself,  and  then  urination  is  encouraged  by  hot  fomenta- 
tions to  the  pubes  and  running  water.  If  these  fail,  the  catheter  may  be 
employed.  In  every  case  j  gr.  of  morphin  should  be  given  subcutane- 
ously  before  the  patient  leaves  the  table,  and,  where  the  clamp  method 
has  been  employed,  this  will  probably  be  necessary  every  four  hours, 
as  the  pain  is  usually  intense. 

Complications  and  Sequelae. — Hemorrhage. — The  ends  of 
the  broad  ligaments  are  brought  down  into  the  vagina  after  being 
seized  with  a  volsellum  forceps,  and  the  bleeding  point  found,  clamped, 
and  ligated.  If  ligation  is  impossible,  or  the  patient  is  in  a  very  poor 
condition,  the  clamp  is  left  in  place  for  forty-eight  hours.  In  some 
instances  it  will  be  necessary  to  include  the  whole  end  of  the  broad 
ligament  in  the  clamp. 

Sepsis. — The  employment  of  vaginal  drainage  and  the  Fowler's 
position  are  directed  to  the  prevention  and  control  of  infection,  so  that 
no  material  change  in  the  after-treatment  will  be  made  if  infection  does 
occur.  If  there  is  a  sudden  or  steady  rise  of  temperature  to  103°  or  104° 
F.  before  the  fourth  day,  the  wicks  are  changed  immediately,  as  this 
indicates  faulty  drainage.  Where  there  is  a  great  deal  of  purulent  dis- 
charge from  the  sinus,  irrigation  with  a  solution  of  chlorinated  soda 
may  be  employed  after  the  first  week. 


OPERATIONS    ON    THE   CERVIX    UTERI  483 

References 

R.  Olshausen,  Weitere  Erfolge  der  vaginalen  Totalexstirpation  des  Uterus  und  Modi- 
fication des  Technik,  Arch.  f.  Gyn.,  1882,  xx,  373. 

J.  Pean,  De  I'ablation  des  gros  fibromes  interstitiels  du  corps  de  I'uterus  par  la  vou 
perineo-vagino  rectale,  Ann.  de  gyn.,  1894,  xli,  522. 

E.  Doyen,  Technique  Chirurgicale,  Paris,  1897. 

W.  R.  Pryor,  The  Technique  of  Vaginal  Hysterectomy  in  Cases  of  Pehic  Inflamma- 
tion, Amer.  Gynecol.,  1903,  ii,  102. 

OPERATIONS  ON  THE  CERVIX  UTERI 

Under  this  heading  will  be  considered  trachelorrhaphy  and  the 
various  plastic  operations  for  dysmenorrhea,  such  as  Dudley's,  Rey- 
nold's, Pozzi's,  and  others. 

It  may  be  appropriate  to  say  a  word  about  the  method  of  suturing 
the  cervix  in  trachelorrhaphy.  The  sutures  may  be  of  silver  wire  or 
catgut.  The  former  will  give  the  better  cosmetic  result,  but  catgut  is 
much  easier  to  use  and  gives  satisfactory  results  in  everyday  practice. 
If  wire  is  used,  it  is  drawn  through  the  cervix  in  a  silk  carrier,  A  regu- 
lation cervix  needle  of  the  Sims  or  Emmet  type  is  used.  Each  stitch 
enters  the  vaginal  surface  of  the  upper  lip  and  passes  underneath  the 
denudation,  emerging  in  the  edge  of  the  strip  left  undenuded  to  form  the 
wall  of  the  cervical  canal.  It  then  reenters  the  edge  of  this  strip  on  the 
posterior  lip,  and  emerges  again  on  the  vaginal  surface  at  a  point  op- 
posite to  the  original  point  of  entrance.  The  first  stitch  is  placed  near 
the  inner  and  outer  angles  of  the  denudation,  and  each  successive  stitch 
enters  and  emerges  nearer  the  external  os.  On  the  vaginal  surface  the 
stitches  should  enter  and  emerge  I  in.  from  the  edge  of  the  denudation. 
They  should  be  tied  without  too  much  tension. 

The  after-treatment  of  these  several  operations  is  identical.  Before 
leaving  the  table  the  vagina  is  douched  with  sterile  water  and  then 
swabbed  out  with  gauze,  all  blood-clot  being  carefully  removed.  The 
vagina  is  douched  daily  with  sterile  w^ater.  Silver-wire  stitches  should 
be  removed  at  the  end  of  t\vo  weeks.  This  is  most  conveniently  done 
with  the  patient  in  the  Sims  posture,  the  wire  being  picked  up  with  a 
long  clamp  and  cut  with  long-handled  scissors.  When  catgut  has 
been  used,  unless  the  patient  is  a  virgin,  operated  for  dysmenorrhea,  she 
should  report  at  the  surgeon's  office  at  the  end  of  three  weeks,  and  the 
ends  of  the  stitches  picked  off  the  cervix  with  a  long-handled  clamp. 
The  object  of  this  is  to  stop  the  vaginal  discharge  which  is  kept  up  by 
their  presence. 

The  patient  can  take  a  light  meal,  consisting  chiefly  of  soup  or  milk, 
the  evening  after  operation,  and  the  following  morning  may  be  put  at 
once  on  full  diet. 


484      OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

The  bowels  are  regulated  by  mild  laxatives  and  enemas  when  neces- 
sary. 

The  patient  may  sit  up  on  the  ninth  and  get  up  on  the  tenth  day. 

Complications  and  Sequelae. — Hemorrhage  occurs  with  great 
rarity,  but  may  develop  where  deep  denudation  has  been  necessary  to 
remove  all  scar  tissue.  A  firm  gauze  pack  is  placed  against  the  cervix, 
and  if  this  fails  to  stop  the  bleeding,  the  stitches  must  be  removed  and 
new  ones  so  taken  as  to  control  the  bleeding  vessels. 

Injury  to  a  ureter  is  a  more  or  less  theoretic  complication,  and  could 
only  occur  either  due  to  an  atypical  anatomy  of  the  ureter  or  a  consider- 
able lack  of  technique  in  operating. 

References 

T.  A.  Emmet,  Principles  and  Practice  of  Gynecology,  1884,  466. 

E.  C.  Dudley,  A  Plastic  Operation  Designed  to  Straighten  the  Anteflexed  Uterus, 
Amer.  Jour.  Obst.,  1891,  xxiv,  142. 

S.  Pozzi,  On  the  Surgical  Treatment  of  a  Most  Frequent  Cause  of  Dysmenorrhea  and 
Sterility  in  Women,  Surg.,  Gyn.  and  Obstet.,  1909,  ix,  in. 

CURETTAGE  FOR  ABORTION  AND  MISCARRIAGE 

When  the  patient  is  in  a  hospital,  the  uterus  should  not  be  packed 
unless  there  is  considerable  bleeding.     If  the  patient  is  in  a  private 


Fig.  159. — First  Step  in  Packing  the  Vagina. 
Curved  clamp  feeding  gauze  from  left  hand.     Two  fingers  of  left  hand  dilate  vagina. 

house  or  at  a  distance,  it  is  the  part  of  safety  to  pack  firmly  the  uterus 
and  vagina.     The  pack  is  removed  the  next  day  and  the  uterus  and 


CURETTAGE    FOR    ABORTION    AND    MISCARRIAGE 


485 


vagina  left  empty.     No  vaginal  douches  are  to  be  gi^•en  before  the  tenth 
day.  

\       ^ 


Fig.  160. — Second  Step  in  Packing  the  Vagina. 
Tip  of  curved  clamp  has  carried  gauze  to  vault. 


The  bowels  are  to  be  opened  by  an  enema  the  morning  after  opera- 
tion, and  are  kept  open  by  the  daily  administration  of  cathartics. 


Fig.  161. — Packing  the  Vagina  Thkolgh  a  Speculum. 
Gauze  introduced  to  vault. 


Six  hours  after  operation  the  patient  is  able  to  take  nourishment  in 
the  form  of  broth  or  milk.  The  following  morning  she  is  started  on 
soft  solids  and  the  third  day  on  full  diet. 


486 


OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 


She  may  sit  up  on  the  ninth  and  get  up  on  the  tenth  day. 
Complications  and  Sequelae. — Hemorrhage. — When  the  uterus 
is  left  empty,   it  sometimes  becomes  necessary  to   pack  some   hours 


Fig.  162. — Packing  the  Uterus. 
Weighted  speculum;  cervix  held  by  bullet-forceps;   curved  clamp  introduces  gauze  to  fundus. 

later  to  control  hemorrhage.     When  the  uterus  has  been  firmly  packed, 
serious  hemorrhage  is  impossible.     Sometimes  after  removal  of  the 


Fig.  163. — Removing  Gauze  Pack  From  Uterus. 
Fingers  of  left  hand  in  vagina. 


packing  a  slight  hemorrhage  starts  up.  If  this  does  not  cease  within 
a  few  minutes,  the  uterus  should  be  repacked  with  sterile  gauze.  This 
may  be  removed  twenty-four  hours  later  with  perfect  safety. 


SEPSIS    AFTER   ABORTION    OR    MISCARRIAGE  487 

Infection. — Many  cases  of  miscarriage  are  slightly  infected  before 
operation,  as  is  shown  by  a  moderate  degree  of  temperature.  This,  as 
a  rule,  drops  to  normal  within  twenty-four  hours  after  curettage.  Occa- 
sionally, within  from  twenty-four  to  forty-eight  hours  after  operation, 
there  will  be,  with  or  without  a  chill,  a  sudden  rise  of  temperature  to  103° 
or  104°  F.  This  is  usually  due  to  a  clot  blocking  up  the  cervix,  and  if 
left  to  nature,  the  clot  will  usually  be  expelled  and  the  temperature  will 
drop  to  normal  again  within  twenty-four  hours.  If,  however,  the  tem- 
perature does  not  begin  to  drop  within  twelve  hours,  the  cervix  should 
be  gently  dilated  and  the  uterus  washed  out  with  four  quarts  of  sterile 
water.  If  the  temperature  still  persists,  a  culture  should  be  taken 
from  the  interior  of  the  uterus  with  a  Doederlein  tube,  and  if  a  growth 


Fig.  164. — Introducing  the  Intra-uterine  (Leonard")  Douche-tcbe. 

is  obtained,  a  vaccine  should  be  prepared  from  it.  The  vaccine  treat- 
ment of  puerperal  infection  is  as  yet  experimental,  but  the  operator  is 
not  justified  in  leaving  untried  any  treatment  which  may  aid  the  re- 
covery of  the  patient.  (See  Chapter  LII.)  The  uterus  should  then 
be  washed  out  as  before,  and  this  time  the  uterine  caA'ity  should  be 
packed  with  a  gauze  sponge  soaked  in  70  per  cent,  alcohol.  This  is 
repeated  daily  until  the  temperature  begins  to  fall,  or  the  uterus  shuts 
down  so  that  the  douche-tube  cannot  be  inserted.  When  the  tempera- 
ture does?  not  drop  after  the  curettage,  the  uterus  should  be  washed 
out  immediately  after  the  packing  is  removed,  after  which  the  case 
should  be  conducted  as  described  above. 

When  the  miscarriage  has  been  voluntarily  induced,  a  culture  should 


488 


OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 


be  taken  before  curettage,  because  infection  is  likely  to  be  virulent,  and 
a  vaccine  should  be  ready  for  early  use  if  emptying  the  uterus  does  not 
bring  about  a  drop  in  temperature. 

In  addition  to  the  local  treatment,  general  measures  are  of  great 
value.  The  patient  should  be  kept  out-of-doors  during  the  day,  no 
matter  whether  winter  or  summer.  Strychnin  sulphate,  gr.  -gl^,  and 
whisky  may  be  given  every  four  hours.  Nourishment  should  be 
forced — eggs,  milk,  cereals,  broths,  and  meat  being  allowed,  no  matter 
how  high  the  temperature. 

The  pelvis  should  be  examined  every  third  day  at  least  during  the 
course  of  the  fever,  so  that  any  abscess  in  the  broad  ligaments  will  be 
detected  and  may  be  opened.     Localized  foci  which  may  develop  in 


Fig.  165. — Intra-uterine  Irrigation. 

any  organ  from  pyemia  should  be  watched  for  and  treated.  The 
commonest  of  these  are  pneumonia,  endocarditis,  and  joint  infections. 

General  Peritonitis. — This  usually  follows  perforation  of  the  uterus 
in  the  attempt  at  criminal  abortion,  but  may  result  from  accidental 
perforation  by  a  curet  in  the  hands  of  a  skilful  operator. 

The  best  treatment  is  vaginal  drainage  by  posterior  colpotomy,  as 
described  in  the  section  on  Pelvic  Abscess  (p.  478),  followed  by  the 
Murphy  treatment.  Fowler's  position,  continuous  rectal  saline,  etc. 

Pelvic  Abscess. — (See  p.  478.) 

Salpingitis. — Salpingitis  due  to  puerperal  infection  is  commonly 
unilateral.  It  usually  develops  in  the  second  week  of  convalescence, 
and  is  characterized  by  an  elevation  of  temperature,  with  pain,  tender- 
ness, and  spasm  over  one  or  both  lower  quadrants  of  the  abdomen. 


CURETTAGE    FOR    ENDOMETRITIS    OR    ANTEFLEXION  489 

The  treatment  is  rest  in  bed,  liquid  diet,  free  catharsis,  hot  flaxseed 
poultices  to  the  abdomen  every  two  hours,  and  hot  douches  t^vice  daily. 
The  acute  process  will  subside  in  seven  to  ten  days,  and  salpingo-oophor- 
ectomy  may  be  done  later  if  the  tube  remains  enlarged. 

Perforation  of  the  Uterus. — Any  surgeon  who  has  curetted  many 
uteri  has  probably  perforated  at  least  one.  Frequently  there  is  ab- 
solutely no  ill  effect.  The  occurrence  is  recognized  by  the  curet  sud- 
denly passing  into  the  uterus  up  to  the  handle.  When  this  happens,  the 
curet  should  be  withdrawn  and  all  further  maneuvers  stopped.  The  pa- 
tient is  put  to  bed  in  the  Fowler  position.  The  pulse  is  recorded  every  half- 
hour  for  twelve  hours  and  a  four-hourly  chart  is  kept  for  three  days.  For- 
tunately, this  accident  seldom  happens  until  the  uterus  is  nearly  or  quite 
empty;  in  fact,  it  usually  results  from  an  overdesire  to  get  the  uterus 
clean,  so  that  there  will  be  no  need  to  pack  the  uterus.  If  there  is  much 
bleeding,  however,  the  uterus  should  be  packed  lightly  and  carefully. 
If  there  is  a  steadily  rising  pulse,  the  abdomen  should  be  opened  and 
the  perforation  in  the  uterus  closed,  and  injury  to  the  intestine  sought 
for.  The  abdomen  should  be  closed  with  a  wick  to  the  point  of  injury. 
A  provisional  stitch  may  be  inserted  at  the  site  of  the  drain.  After 
forty-eight  hours  the  wick  is  removed  and  the  stitch  tied. 

If,  after  the  uterus  has  been  accidentally  perforated,  there  appears 
upon  the  four-hourly  chart  a  steady  rise  of  temperature  and  pulse, 
together  with  increasing  pain  and  tenderness  in  the  lower  abdomen, 
celiotomy  should  be  performed  at  once.  The  uterine  w^ound  should 
be  sewed  up  and  the  pelvic  cavity  drained.  If  peritonitis  is  found,  the 
regulation  Murphy  treatment  is  instituted. 

References 

A.  Pinard,  Traitement  des  Infections  Puerperals,  Ann.  de  gyn.,  1909,  vi,  577. 
L.  V.  Friedman,  Puerperal  Salpingitis,  Surg.,  Gyn.  and  Obst.,  1908,  vii,  476. 
A.  P.  Heineck,  Perforating  Wounds  of  the  Uterus  Inflicted  During  the  Course  of 
Intra-uterine  Instrumentation,  Surg.,  Gyn.  and  Obst.,  1908,  ^di,  424. 

H.  M.  Stowe,  The  Treatment  of  Abortion,  Surg.,  Gyn.  and  Obst.,  19 10,  x,  80. 

CURETTAGE  FOR  ENDOMETRITIS  OR  ANTEFLEXION 
These  will  be  considered  together  because  their  after-care  is,  for 
the  most  part,  identical.  When  the  operation  has  been  performed  for 
endometritis,  the  uterus  is  simply  wiped  out  with  dry  sterile  gauze,  then 
with  gauze  saturated  with  Churchill's  tincture  of  iodin,  and  left  empty. 
Where  an  anteflexed  uterus  has  been  dilated  and  curetted,  the  inter- 
nal OS  is  kept  open  by  means  of  a  stem  pessary.  The  uterus  is  carefully 
wiped  out  with  dry  sterile  gauze,  the  pessary  inserted  and  stitched  in 


490     OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

place  by  three  silkworm-gut  stitches  through  the  holes  in  the  flange 
and  the  cervix.  The  vagina  is  left  empty.  This  pessary  is  removed 
at  the  end  of  ten  days.  The  patient  is  placed  in  the  Sims  posture  and 
the  cervix  exposed.  The  sutures  are  cut  with  long-handled  scissors, 
and  after  this  the  pessary  can  be  made  to  slip  out  by  very  slight  traction 
upon  the  flange. 

The  bowel  should  be  opened  by  enema  the  morning  after  operation, 
and  kept  open  by  daily  catharsis.  Six  hours  after  operation  the  patient 
may  take  some  hot  broth  or  hot  milk.  The  next  morning  she  returns 
to  full  diet.  The  patient  may  sit  up  on  the  sixth,  and  get  up  on  the 
seventh,  day. 

Complications. — Perforation  of  the  uterus  may  occur.  An  old 
salpingitis  which  has  lain  dormant  for  some  time  may  be  lighted  up  by 
a  curettage.  What  has  just  been  said  about  these  conditions  under 
curettage  for  miscarriage  apply  here  also. 

SYMPHYSIOTOMY 

After  the  delivery  of  the  child  the  bladder  is  catheterized,  and  if 
bloody  urine  is  withdrawn,  an  injury  to  the  bladder  is  looked  for  and 
repaired.  When  the  open  method  has  been  employed,  the  pubic  liga- 
ments are  united  and  the  skin  w^ound  closed  with  a  small  gauze  drain  in 
the  lower  angle.'  With  the  subcutaneous  method  no  sutures  are  possible 
except  one  or  t^vo  in  the  skin  at  the  upper  opening.  In  the  latter  case 
a  gauze  wick  is  passed  into  the  lower  opening.  After  either  method  a 
sterile  gauze  dressing  is  applied  and  held  in  place  by  adhesive  straps. 
A  strong  canvas  belt  extending  from  just  above  the  crests  of  the*  ilia 
to  6  in.  below  the  trochanters,  and  well  padded  with  cotton  over  the 
prominences,  is  feuckled  about  the  pelvis.  The  patient  is  put  to  bed 
with  a  sand-bag  beneath  each  trochanter.  The  wound  is  inspected 
at  the  end  of  forty-eight  hours,  and  the  wick  left  out  unless  suppura- 
tion occurs.  Stitches  are  removed  on  the  tenth  day.  The  vulva  is 
kept  covered  with  a  sterile  pad,  and  is  irrigated  with  sterile  water  after 
each  urination  or  defecation.  . 

Catheterization  should  be  employed  at  the  end  of  tAvelve  hours  if 
the  patient  does  not  urinate  spontaneously,  and  every  eight  hours  there- 
after if  necessary. 

The  bowels  are  moved  by  castor  oil  on  the  evening  of  the  second 
day  and  kept  open  by  daily  catharsis  if  necessary. 

The  diet  is  liquid  for  forty-eight  hours;  soft  solid  on  the  third  day; 
chicken  added  on  the  fourth,  and  full  diet  begun  on  the  fifth  day. 

The  care  of  the  breasts  and  other  details  of  management  of  the 


SYMPHYSIOTOMY 


491 


puerperium  do  not  differ  materially  from  those  after  any  obstetric  case. 
The  patient  is  kept  in  bed  four  weeks,  and  wears  a  firm  belt  about  the 
pelvis  for  three  months.  At  the  end  of  this  time  she  is  able,  as  a  rule,  to 
resume  her  ordinary  habits  of  life. 

Complications  and  Sequelae.— /w/ec//ow.— Uterine  infection, 
which  is  extremely  common  in  the  cases  requiring  symphysiotomy,  is 
manifested  and  treated  no  differently  from  sepsis  after  any  other  method 
of  delivery,  as  described  in  the  section  on  Miscarriage.  Infection  of  the 
wound  is  also  common  and  is  treated  the  same  as  any  other  infected 
wound.  An  absolutely  afebrile  convalescence  from  symphysiotomy  is 
almost  unknown. 

Hemorrhage  from  the  venous  plexus  behind  the  symphysis  is  always 
present  at  operation,  and  sometimes  is  not  controlled  by  the  sutures  and 
dressing,  but  requires  packing. 

Injury  to  the  bladder  is  a  frequent  complication.  It  should  be  dis- 
covered at  operation  and  repaired.  If  this  is  not  done,  a  urinary  fistula 
develops.  Whenever  the  bladder  is  injured,  whether  repaired  or  not, 
constant  drainage  by  means  of  a  self-retaining  catheter  should  be  in- 
stituted, and  the  catheter  removed,  cleaned,  boiled,  replaced,  and  the 
bladder  washed  out  with  6  ounces  of  4  per  cent,  boric-acid  solution 
twice  daily.  This  is  kept  up  for  ten  days.  If  the  injury  has  not  been 
repaired  or  repair  is  unsuccessful,  the  fistula  must  be  closed  by  opera- 
tion at  a  later  day. 

Perineal  and  vaginal  tears  are  common  and  should  be  repaired. 
Their  after-treatment  does  not  vary  from  that  described  in  the  section 
devoted  to  them. 

Injury  to  the  sacro-iliac  joints  from  too  great  separation  of  the  sym- 
physis results  in  severe  backache  and  interference  with  locomotion.  This 
is  treated  by  a  tight  canvas  or  leather  belt,  which  must  be  worn  for  from 
six  months  to  a  year.  A  plaster-of-Paris  jacket  may  be  necessary  for 
a  time. 

Hematoma  of  the  labium  from  hemorrhage  from  the  prevesical  plexus 
is  common.  Even  very  extensive  ecchymosis  and  moderate-sized 
hematomas  are  cared  for  by  nature.  When  a  hematoma  develops  ex- 
cessive size  or  persists  after  ten  days  or  two  weeks,  it  should  be  incised, 
its  contents  evacuated,  and  the  cavity  packed. 

Failure  of  union  at  the  joint,  with  considerable  mobility  of  the  pubic 
bones,  resulting  in  a  permanent  impairment  of  gait,  occasionally  follows 
this  operation. 

Cystitis  'is  common,  especially  where  the  bladder  has  been  injured. 
For  treatment,  see  Chap.  XIV.,  p.  136. 


492 


OPERATIONS    ON    THE    VAGINA,    UTERUS,    AND    ADNEXA 


PUBIOTOMY 

What  has  already  been  said  about  symphysiotomy  applies  in  the 
main  also  to  pubiotomy.  The  convalescence,  however,  is  more  rapid  and 
freer  from  complications.  The  patient  is  able  to  get  out  of  bed  on  the 
twenty-first  day  instead  of  at  the  end  of  four  weeks,  and  normal  locomo- 
tion is  possible  much  sooner  than  after  symphysiotomy. 


Mi  3S  . 

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Fig.  166. — Ventrosuspension.    Slight  Aseptic  Reaction. 

The  same  complications  occur,  but  less  frequently.  Failure  of  union 
seems  to  make  no  appreciable  difference  in  locomotion,  as  a  firm  fibrous 
union  takes  place  in  these  cases. 

The  belt  may  be  omitted  at  the  end  of  four  weeks,  instead  of  being 
worn  for  three  months,  as  in  symphysiotomy. 

References 

J.  R.  Sigault,  Discours  sur  les  avantages  de  la  section  de  la  symphyse  dans  les  ac- 
couchements,  Paris,  1779. 

R.  P.  Harris,  The  Remarkable  Results  of  Antiseptic  Symphysiotomy,  Trans.  Amer. 
Gyn.  Soc,  1892,  xvii,  98. 

P.  Zweifel,  Die  subcutane  Symphyseotomie,  Centr.  f.  Gyn.,  1906,  xxx,  737. 


OVARIOTOMY  493 

L.  Gigli,  Taglio  lateralizzato  del  pube,  sua  vantaggi,  sua  tecnica,  Ann.  di  os.  e.  gin., 
1894,  xvi,  649. 

A.  Doderlein,  Ueber  alte  u.  neue  beckenerweiternde  Operationen,  Arch.  f.  Gyn., 
1904,  Ixxii,  275. 

E.  Bumm,  In  Stoeckel,  Symphyseotomie  oder  Pubiotomy,  Centr.  f.  Gyn.,  1906,  xxx,  78. 
C.  G.  Leopold,  In  Kannegeisser,  Beitrage  zur  Hebotomie  auf  Grund  von  21  Falle, 

Arch.  f.  Gyn.,  1906,  Ixxviii,  52. 

C.  B.  Reed,  Pubiotomy,  Amer.  Jour.  Obstet.,  1909,  Ix,  100. 

OPERATIONS  FOR  RETROVERSION  AND  LESSER  OPERATIONS  ON 

THE  APPENDAGES 

For  the  sake  of  convenience  I  have  grouped  together  the  numerous 
abdominal  operations  for  retroversion  and  the  minor  operations  on 
the  appendages,  such  as  resections  of  the  tubes  and  ovaries  and  removal 
of  small  ovarian  cysts,  since  the  general  principles  of  after-treatment 
are  practically  identical,  and  the  several  operations  are  frequently 
combined. 

Dressing. — Such  cases  are  practically,  without  exception,  closed 
tightly  in  layers,  and  a  thin  dressing  of  sterile  gauze  held  by  adhesive 
straps  or  laced  plaster  (Fig.  144,  p.  456)  is  placed  over  the  wound.  The 
stitches  are  removed  on  the  tenth  day. 

If  an  operation  for  displacement  of  the  uterus  has  been  done,  the 
patient  is  not  allowed  to  sit  up  in  bed  until  the  twelfth  day,  or  to  get 
out  of  bed  before  the  fourteenth.  On  the  other  hand,  if  only  the  ap- 
pendages have  been  operated  upon,  she  may  sit  up  before  removal  of 
the  stitches  and  get  up  on  the  seventh  day. 

The  general  after-treatment  and  complication  do  not  vary  from 
those  of  any  of  the  simpler  celiotomies. 

References 

H.  A.  Kelly,  Hysterorrhaphy,  Amer.  Jour.  Obst.,  1887,  xx,  33. 

R.  Olshausen,  Ueber  ventrale  Operationen  bei  Prolapsus  und  Retroversio  uteri, 
Centr.  f.  Gyn.,  1886,  x,  698. 

J.  C  Webster,  A  Satisfactory  Operation  for  Certain  Cases  of  Retroversion  of  the 
Uterus,  Jour.  Amer.  Med.  Assoc,  1901,  xxxvii,  913. 

J.  M.  Baldy,  Retrodisplacements  of  the  Uterus  and  Their  Treatment,  New  York 
Med.  Jour.,  1903,  Ixxviii,  167. 

D.  T.  Gilliam,  Round  Ligament  Ventrosuspension  of  the  Uterus,  Amer.  Jour.  Obst., 
1900,  xli,  299. 

F.  F.  Simpson,  Intra-abdominal-  but  Retroperitoneal  Shortening  and  Anterior  Fixation 
of  the  Round  Ligaments  for  Posterior  Uterine  Displacements,  Trans.  Southern  Surg,  and 
Gyn.  Soc.,,  1902,  xv,  223. 

OVARIOTOMY 

The  after-treatment  of  removal  of  uncomplicated  simple  cysts, 
even  of  large  size,  is  identical  with  that  described  for  the  lesser  opera- 


494     OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND .  ADNEXA 

tions  upon  the  appendages.  These  constitute  the  majority  of  ovariot- 
omies. 

Drainage  is  required  only  when  there  have  been  many  adhesions  of 
the  cyst  to  the  walls  and  floor  of  the  pehas,  as  a  result  of  the  separation 
of  which  a  large  oozing  surface  is  left  behind  which  cannot  be  controlled 
by  sutures;  whenever  there  has  been  infection,  either  in  the  cyst  contents 
or  the  peritoneal  ca\'ity;  after  the  removal  of  malignant  tumors  where 
there  is  ascites,  and  when  a  dermoid  cyst  has  been  accidentally  ruptured 
in  removal  and  its  contents  have  escaped  into  the  peritoneal  cavity. 
An  oozing  surface  requires  a  single  gauze  pack  making  firm  pressure 
against  it.  Where  there  has  been  ascites  or  infection,  it  is  best  to  pass 
a  drain  behind  each  broad  ligament,  although  the  tumor  may  have 
been  unilateral.  Where  a  dermoid  cyst  has  been  ruptured,  a  single  drain 
which  passes  down  behind  the  stump  of  the  broad  ligament  on  the 
affected  side  and  into  the  posterior  culdesac  is  sufficient. 

The  simple  exploration  of  the  abdomen  where  a  papillary  adeno- 
cystoma is  found,  and,  after  evacuating  the  free  fluid,  the  wound  is 
immediately  closed,  does  not  require  drainage,  but  if  attempts  at  re- 
moval of  the  growth  have  been  made,  a  wick  should  be  placed  behind 
each  ligament.  In  some  cases  an  ovarian  cyst  is  so  adherent  as  a 
result  of  peritonitis  that  it  is  impossible  to  do  more  than  evacuate  the 
cyst  contents  and  remove  part  of  the  cyst-wall.  In  this  instance  a  wick 
should  be  passed  into  the  cavity  of  the  cyst,  and  a  second  one  into  the 
abdomen  just  above  the  cyst,  to  wall  off  the  pelvis  from  the  general 
peritoneal  cavity. 

When  the  drainage  has  been  simply  to  control  oozing,  a  provisional 
through-and-through  suture  of  silkworm  gut  is  inserted  at  the  time  of 
operation  at  the  site  of  exit  of  the  drain.  At  the  end  of  forty-eight 
hours  the  drain  is  removed  and  the  provisional  stitch  tied.  Healing 
by  first  intention  is  the  rule.  In  any  other  case  drains  are  removed 
on  the  fourth  day,  and,  as  a  rule,  can  be  replaced  by  a  single  small  wick, 
which  is  left  out  altogether  the  following  day.  The  edges  of  the  wound 
are  then  brought  together  by  adhesive  strapping,  and  the  dressing 
changed  every  other  day,  as  by  this  time  the  edges  of  the  drained  area 
will  be  practically  united. 

Cases  closed  tight  and  those  in  which  a  provisional  stitch  is  em- 
ployed with  success  get  up  on  the  fifth  day.  Drained  cases  usually 
may  sit  up  on  the  twelfth,  and  get  up  on  the  fourteenth,  day. 

Complications  and  Sequelae. — The  complications  of  celi- 
otomy for  this  condition  are  the  same  as  those  for  celiotomies  in  general. 

Slipping  of  a  Ligature  on  the  Pedicle. — This  occasionally  occurs. 


SALPIXGO-OOPHORECTOMY  FOR  SALPINGITIS  AND  OVARIAN  ABSCESS    495 

The  symptoms  are  those  of  secondary  hemorrhage.     The  treatment  is 
to  reopen  the  abdomen  and  retie  the  pedicle. 

Injury  to  the  Bowel. — This  comphcation  may  result  from  the  separa- 
tion of  an  adherent  cyst  from  any  part  of  the  bowel.  The  injury  should 
be  repaired  at  the  time  of  operation,  and  a  gauze  drain  inserted  to  the 
injured  area,  to  be  removed  on  the  fourth  day.  If  a  fecal  fistula  develops, 
the  wicks  are  left  out.  The  edges  of  the  wound  and  the  surrounding 
skin  are  smeared  with  stearate  of  zinc  ointment.  After  the  seventh 
day  the  fistula  is  irrigated  t^vice  daily  with  chlorinated  soda  in  i :  800 
solution.  Spontaneous  closure  usually  takes  place  in  from  two  to  three 
weeks.  If  the  fistula  shows  no  signs  of  closing  down  after  six  weeks, 
operative  measures  should  be  resorted  to  for  its  closure.  (See  also 
Chap.  XXV,  p.  246.) 

Injury  to  Bladder  or  Ureter. — These  complications  occur  only  with 
extreme  rarity.  Their  treatment  will  be  the  same  as  is  described  under 
Hysterectomy  fp.  501). 

Referenxe 

A.  J.  C.  Skene  in  Kelly-Xoble,  Gynecolog}'  and  Abdominal  Surgery,  1907,  i,  587. 

SALPINGO-OOPHORECTOMY    FOR    SALPINGITIS     AND    OVARIAN 

ABSCESS 

Dressing's. — Wicks  may  be  necessary  for  either  of  two  indications: 
first,  after  separating  adhesions  an  oozing  surface  which  cannot  be  con- 
trolled by  sutures;  second,  whenever  pus  has  escaped  into  the  pelvis 
in  the  process  of  separating  and  removing  the  diseased  organs.  In  the 
first  instance  a  single  wick  is  passed  to  the  oozing  surface,  or  one  to 
each,  if  there  is  an  uncovered  area  on  both  sides  of  the  pelvis,  and  a 
provisional  through-and-through  silkworm-gut  stitch  is  taken  at  the 
site  of  exit  of  the  wick.  At  the  end  of  forty-eight  hours  the  wick  is 
removed  and  the  stitch  tied.  The  wound  is  inspected  again  two  days 
later,  and  if  the  stitch  is  found  to  be  holding,  the  woimd  is  not  disturbed 
again  until  the  tenth  day,  when  all  the  stitches  are  removed. 

When  drainage  is  required  because  of  pus,  a  wick  is  passed  behind 
each  broad  ligament,  if  the  operation  has  been  bilateral,  in  such  a  way 
that  the  two  meet  in  the  posterior  culdesac  and  emerge  side  by  side 
in  the  lower  angle  of  the  wound.  In  this  way  the  pelvis  is  walled  off 
completely  across.  Where  operation  is  performed  only  on  one  side, 
the  drain  should  be  passed  behind  the  broad  ligament  and  over  into 
the  posterior  culdesac,  and  then  brought  out  in  the  lower  angle  of  the 
wound.     The  wicks  are  removed  on  the  fourth  day  and  replaced  by 


496      OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

smaller  wicks,  one  running  to  each  sinus.  At  the  third  dressing  a  single 
wick  to  the  bottom  of  the  pelvis  is  usually  sufficient.  After  the  tem- 
perature becomes  normal,  usually  about  the  fifth  day,  this  wick  is 
shortened  an  inch  daily,  and  when  the  sinus  has  closed  to  two  inches  in 
depth,  it  is  omitted  entirely.  The  wound  is  then  filled  with  glycerin  or 
balsam  of  Peru.  The  stitches  are  removed  on  the  tenth  day,  but  the 
dressing  over  the  wound  is  changed  daily  until  the  sinus  is  closed. 
When  discharge  from  the  sinus  has  practically  ceased,  healing  may  be 
hastened  by  strapping  together  the  edges  of  the  wound. 

When  the  uterus  is  removed  with  the  appendages,  the  method  of 
dressing  is  the  same  as  when  both  sides  have  been  removed  without 
the  uterus.  The  wicks  are  passed  behind  the  stumps  of  the  broad 
ligaments  in  the  same  manner,  and  brought  together  in  the  posterior 
culdesac,  so  as  to  cover  over  the  stump  of  the  cervix  and  make  their  exit 
from  the  wound  in  the  same  manner. 

Sometimes  after  the  temperature  has  once  dropped  to  normal  a 
sudden  or  gradual  rise  again  occurs,  accompanied  by  pain  in  the  depths 
of  the  wound.  This  signifies  backing  up  in  the  sinus,  with  formation 
of  a  pus-pocket.  The  treatment  is  to  explore  the  wound  with  the  finger 
under  primary  ether,  dilating  the  sinus  until  the  characteristic  fluctuant 
feel  of  a  pus-pocket  is  detected.  Dilatation  of  the  sinus  is  continued 
until  the  pus-pocket  is  entered  and  emptied.  A  drain  is  carefully 
passed  to  the  bottom  of  the  pocket  and  left  undisturbed  for  forty-eight 
hours,  after  which  it  is  changed  daily,  gradually  being  shortened  as  the 
temperature  falls  and  the  pocket  closes  in. 

Stay  in  Bed. — When  the  abdomen  has  been  closed  without 
drainage,  or  where  a  provisional  stitch  has  been  employed,  the  patient 
may  sit  up  in  bed  on  the  ninth,  and  get  out  of  bed  on  the  tenth,  day. 
The  stay  in  bed  of  the  drained  cases  will  naturally  vary  considerably. 
A  safe  rule  to  follow  is  not  to  let  the  patient  out  of  bed  until  the  sinus  is 
closed  above  the  level  of  the  fascia,  and  then  only  with  a  firm  adhesive 
strap  upon  the  wound.  Otherwise,  the  general  rules  for  after-treatment 
of  celiotomies  apply  to  this  operation. 

Complications  and  Sequelae. — Injury  to  Boivel. — Either  the 
rectum,  sigmoid,  or  small  intestine  may  be  injured  in  separating  a 
densely  adherent  tube.  If  this  is  discovered  at  the  time  of  operation, 
the  injury  should  be  repaired,  after  which  an  extra  drain  is  passed 
especially  to  wall  off  the  injured  bowel.  This  drain  is  removed  at  the 
same  time  as  the  others.  Enemas  should  be  avoided  if  the  injury  has 
been  to  the  rectum  or  sigmoid,  and  the  bowels  kept  open  if  possible  by 
catharsis  alone.     If  a  fecal  fistula  results,  the  drains  must  be  omitted 


SALPINGO-OOPHORECTOMY  FOR  SALPINGITIS  AND  OVARIAN  ABSCESS    497 

entirely  and  the  skin  about  the  wound  smeared  thickly  with  stearate  or 
oxid  of  zinc  ointment.  After  the  seventh  day  the  fistula  is  irrigated 
twice  daily  with  i :  800  chlorinated  soda  solution,  and  a  copious  rectal 
irrigation  with  salt  solution  is  given  once  daily.  Spontaneous  healing 
in  two  or  three  weeks  is  the  rule  in  small  fistulae.  It  is  not  harmful,  and, 
in  fact,  better  for  the  health  of  the  patient  to  get  her  out  of  bed  at  the 
end  of  three  weeks,  even  if  the  fistula  has  not  closed.  If  the  fistula 
shows  no  signs  of  fiUing  in  after  six  weeks,  it  should  be  closed  by  opera- 
tion. 

Injury  to  the  Bladder  and  Ureters.— These  are  very  uncommon 
complications  of  the  operations  for  salpingitis  and  ovarian  abscess. 
They  are  usually  caused  by  needle-pricks.  If  the  injury  is  discovered 
at  the  time  it  is  done,  the  bladder  or  ureteral  wound  should  be  closed 
in  with  several  fine  Pagenstecher  sutures.  The  drain  is  then  disposed 
so  as  to  wall  this  area  off  from  the  peritoneal  cavity.  If  the  suture 
has  been  unsuccessful  or  the  injury  has  not  been  discovered  at  the  time 
of  operation,  the  odor  of  urine  will  be  found  upon  the  wicks  at  the 
first  dressing.  In  this  case  it  will  be  difficult  to  avoid  infection,  but,  so 
far  as  possible,  the  wound  should  be  kept  clean  and  the  skin  about  it 
protected  from  maceration.  Irrigation  of  the  wound  is  contraindicated. 
The  repair  of  the  fistula  must  be  deferred  until  the  wound  has  become 
practically  clean. 

Phlebitis. — Thrombosis  of  the  uterine,  internal  iliac,  and  common 

iliac  veins  in  succession,  while  less  common  than  after  operations  on  the 

uterus,  occurs  with  considerable   frequency.      (See  Chap.  IX.,  p.  99.) 

Its  onset  is  usually  in  the  second  or  third  week.     The  symptoms  are 

pain  in  the  thigh,  edema  of  the  entire  thigh  and  leg,  and  slight  elevation 

of  temperature.     The  treatment  is  rest  and  elevation  by  the  use  of  a 

pillow  and  side  splints.     The  patient  is  kept  in  bed  for  at  least  one  week 

after  all  swelling  has  subsided — i.  e.,  a  total  period  of  six  to. eight  weeks. 

Citric  acid  in  20-gr.  doses  three  times  a  day  may  be  given,  though  the 

citric  acid  treatment  of  phlebitis  is  still  perhaps  experimental.     When 

the  patient  gets  out  of  bed,  she  should  wear  a  flannel  bandage.     There 

will  be  some  swelling  of  the  ankle,  whenever  the  patient  is  on  her  feet 

.  a  great  deal,  for  six  months  or  a  year,  and  the  bandage  should  be  worn 

during  this  period. 

References 

H.  A.  Kelly,  Operative  Gynecol.,  1906,  ii,  270. 

S.  E.  Tracy,  Preparatory  and  After-treatment  of  Celiotomy  Cases,  Surg.,  Gyn.  and 
Obst.,  1909,  viii,  645. 


32 


498  OPERATIONS    ON   THE   VAGINA,    UTERUS,    AND   ADNEXA 

TUBERCULOUS  SALPINGITIS 

This  deserves  especial  attention  because  the  management  of  the 
after-care  differs  decidedly  from  that  of  other  form.s  of  salpingitis.  x\t 
the  operation  all  the  tuberculous  pelvic  organs  should  be  removed, 
including,  in  many  cases,  the  uterus.  The  abdomen  is  then  closed  with- 
out drainage,  because  if  drainage  is  instituted,  the  walls  of  the  sinus  be- 
come infected  with  tubercle  and  the  sinus  is  likely  to  persist  indefinitely. 
The  patient  should  be  got  out-of-doors  by  the  fifth  day,  and  the  regula- 
tion dietetic  and  hygienic  measures  for  the  treatment  of  tubercLilosis 
instituted.  After  this  time  the  case  is  to  be  regarded  solely  as  one  of 
tuberculosis  and  treated  accordingly.  The  wound  is  inspected  on  the 
tenth  day  and  the  stitches  removed.  The  time  of  getting  up  is  to  be 
governed  by  the  temperature,  as  in  any  case  of  tuberculosis. 

Complications  and  Sequelae. — Tuberculosis  in  Other  Organs.^ 
Some  involvement  of  the  peritoneum  is  invariable  except  in  the  very 
earliest  stage.  Opening  the  abdominal  cavity  and  removing  the  major 
focus  of  infection  frequently  is  followed  by  cure. 

Tuberculosis  of  the  intestines,  pulmonary  tuberculosis,  and  general 
miliary  tuberculosis  are  also  frequent  complications.  In  all  cases  it 
must  be  remembered  that  once  the  tuberculous  focus  has  been  removed 
as  far  as  possible  and  the  peritoneal  cavity  has  been  exposed  to  air, 
light,  or  whatever  the  agency  is  which  is  so  effective  in  many  of  these 
cases,  the  case  becomes  one  of  tuberculosis  instead  of  salpingitis  and  is 
to  be  treated  accordingly. 

Injury  to  the  Boicel. — Large  tuberculous  tubes  and  tuberculous  pelvic 
abscesses  frequently  become  densely  adherent  to  the  rectum,  and  the 
pus  burrows  into  the  rectal  wall.  Under  such  circumstances  injury 
to  the  rectum  is  unavoidable.  This  is  the  gravest  possible  complica- 
tion. The  friable  condition  of  the  rectal  wall  makes  repair  difficult. 
The  omentum  and  sigmoid  are  usually  adherent  or  involved  with  tubercle 
to  such  an  extent  that  they  cannot  be  brought  down  to  cover  over  the 
weak  place.  Finally,  with  the  tuberculous  condition  of  the  rectal  wall 
itself,  these  factors  all  tend  to  the  establishment  of  a  fecal  fistula,  which 
becomes  a  tuberculous  sinus,  and  is,  therefore,  likely  to  persist  indefinitely 
until  the  patient,  weakened  by  the  disease  and  the  fistula,  succumbs. 

If  the  rectum  is  injured,  it  should  be  stitched  over  as  well  as  pos- 
sible. A  drain  has  then  to  be  inserted;  it  should  be  placed  not  directly 
against  the  stitches,  but  a  little  higher  up,  so  as  to  wall  off  the  wounded 
part  of  the  rectum,  but  to  avoid  direct  contact  with  it,  otherwise,  remov- 
ing the  drain  would  increase  the  danger  of  fistula  by  breaking  up  adhe- 
sions.   The  local  treatment  of  such  a  fistula  is  the  same  as  for  anv  other 


ABDOMINAL    HYSTERECTOMY  499 

fecal  fistula,  but  hygienic  measures  are  of  the  utmost  importance.  At- 
tempts at  repair  are  practically  hopeless. 

Either  the  sigmoid  or  the  small  intestine  may  be  adherent  to  a  tuber- 
culous tube  or  abscess  and  occasionally  may  be  injured.  The  prognosis 
is  more  hopeful  than  when  the  rectum  is  injured.  The  treatment  is 
identical,  except  that  after  the  fistula  has  persisted  for  two  months,  an 
attempt  at  dissection  of  the  fistula  and  even  resection  of  the  gut  should 
be  made. 

Ttihercidoiis  Sinus  Persisting  After  Operation. — The  healing  of  a 
sinus  which  persists  after  a  drained  case  is  promoted  chiefly  by  hygienic 
measures.  The  use  of  bismuth  paste  may  be  tried,  but  is  seldom  suc- 
cessful. Repeated  applications  of  tincture  of  iodin  give  the  best  result 
locally.  After  six  months,  if  it  still  persists,  an  attempt  at  dissection  may 
be  made.  It  must  be  remembered  that  bowel  is  frequently  adherent 
at  the  bottom  of  the  sinus,  and  that  such  a  maneuver  may  result  in  a  fecal 
fistula.  It  is  in  some  cases  better  to  leave  the  sinus  altogether  alone 
since,  beyond  the  inconvenience  of  having  to  keep  it  clean  and  covered, 
the  patient  does  not  suffer.  The  treatm.ent  by  the  means  of  vaccine 
therapy  is  often  beneficial.     (See  Chapter  LII.) 

References 

J.  B.  Murphy,  Tuberculosis  of  the  Female  Genitalia  and  Peritoneum,  Amer.  Jour. 
Obst.,  1904,  xlix. 

F.  B.  Lund,  Tuberculosis  of  the  Peritoneum,  Boston  Med.  and  Surg.  Jour.,  1908, 
clix,  885. 

E.  B.  Young,  A  Case  of  Tuberculous  Salpingitis  with  Rupture  into  the  Rectum,  etc., 
Boston  Med.  and  Surg.  Jour.,  1905,  clii,  551. 

W.  H.  Allport,  Tuberculous  Infections  of  the  Peritoneum,  Surg.,  Gyn.  and  Obstet., 
1909,  ix,  529. 

ABDOMINAL  HYSTERECTOMY 

Dressing. — After  the  supravaginal  amputation  of  a  myomatous 
uterus  the  abdomen  is  closed  in  layers  without  drainage,  unless  there 
is  an  amount  of  diffuse  oozing  which  makes  temporary  packing  neces- 
sary. The  first  dressing  is  done  on  the  ninth  day,  and  the  stitches  re- 
moved.    The  patient  gets  up  on  the  tenth  day. 

After  total  extirpation  of  the  uterus  for  malignant  disease,  drainage 
should  always  be  employed.  This  may  be  effected  either  by  a  small 
wick  passed  into  the  vagina  through  a  small  opening  in  the  vault,  or  by 
a  small  abdominal  wick,  according  to  the  preference  of  the  individual 
operator.  In  either  case  the  wick  is  removed  at  the  end  of  forty-eight 
hours  and  replaced  by  a  smaller  one,  which  is  entirely  omitted  after 
twenty-four  hours  more.  If  abdominal  drainage  has  been  employed, 
the  edges  of  the  wound  are  strapped  with  adhesive  plaster.     The  dress- 


500 


OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 


ing  is  changed  every  other  day.  The  stitches  are  taken  out  on  the  ninth 
day,  and  the  patient  may  get  up  on  the  tenth  day.  After  omission  of 
the  vaginal  wick,  nothing  further  is  necessary,  but  a  profuse  vaginal  dis- 
charge may  be  relieved  by  chlorinated  soda  douches  (i :  800)  after  the 
seventh  day. 

The  management  of  bowels,  diet,  etc.,  does  not  differ  from  that 
after  any  celiotomy. 


MrS.      C.      T.      S. 

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Fig.  167. — Abdominal  Hysterectomy. 
Unexplained  continued  temperature.     On  the  thirteenth  day  decomposed  clot  discharged  from  the  amputated 
cervical  canal  with  immediate  drop. 

Hysterectomy,  as  an  adjunct  to  the  removal  of  pus-tubes,  will  be 
considered  under  that  head,  since  the  essential  principles  of  after-treat- 
ment will  be  those  of  operations  for  salpingitis. 

Complications  and  Sequelae.— The  complications  common  to 
celiotomies  in  general  may  occur  after  this  operation.  In  addition  to 
these,  certain  special  complications  deserve  mention. 

Pelvic  Hematoma. — Blood  from  a  slipped  ligature  or  from  an  oozing 
surface  may  collect  under  the  stitched  pehic  floor,  and  give  within  a 
few  hours  great  pain  or  signs  of  hemorrhage.      Vaginal  examination 


ABDOMINAL    HYSTERECTOMY  50I 

shows  a  bulging,  boggy  vault.  Unless  within  a  few  hours  the  symp- 
toms abate,  the  wound  must  be  opened,  the  clot  turned  out,  and  the 
bleeding  stopped.  Slight  oozing  may  give  no  immediate  symptoms, 
but  after  some  days  slight  continued  temperature  (Fig.  167)  and  con- 
stant pain  will  indicate  a  pelvic  collection  of  serum  or  clot.  Douches 
may  lead  to  drainage,  or  it  may  be  necessary  to  dilate  the  cervical 
stump  to  insure  evacuation. 

Ligation  of  the  Ureter. — This  accident  may  occur  in  either  form  of 
hysterectomy,  but  most  frequently  occurs  during  total  extirpation.  If 
only  one  ureter  is  tied  off,  there  are,  as  a  rule,  no  symptoms.  Rarely 
there  may  be  some  pain  in  the  region  of  the  kidney.  When  both  ureters 
are  ligated,  there  is,  of  course,  complete  suppression  of  urine,  and  death 
rapidly  ensues  from  uremia.  If  discovered  in  time,  an  attempt  to  undo 
the  damage  by  operation  should  be  made. 

Injury  to  the  Ureter. — This  occurs  not  infrequently  in  the  course 
of  the  radical  operation  for  cancer  of  the  uterus.  If  discovered  at  the 
time  it  is  done,  the  injury  should  be  repaired  and  a  small  gauze  wick 
placed  to  the  seat  of  suture,  which  is  removed  at  the  end  of  forty-eight 
hours,  and  left  out.  If  the  repair  is  unsuccessful  or  the  accident  is  not 
discovered  at  the  time  of  operation,  urine  is  discharged  from  the  wound 
when  the  wick  is  removed.  In  this  event  the  wound  is  simply  kept  clean 
and  the  parts  protected  from  irritation,  the  repair  of  the  fistula  being  left 
until  a  later  date.  In  the  case  of  an  abdominal  fistula,  these  indications 
are  met  by  wiping  the  skin  about  the  wound  with  70  per  cent,  alcohol 
twice  daily,  after  which  it  is  smeared  with  zinc  ointment,  and  the  w^hole 
covered  with  sterile  gauze.  Where  vaginal  drainage  has  been  employed, 
the  vagina  is  swabbed  out  with  4  per  cent,  boric  acid  solution  twice  daily. 
The  skin  about  the  vulva  is  smeared  with  zinc  ointment  and  a  large 
sterile  pad  worn  over  the  vulva. 

Injury  to  the  Bladder. — This  may  be  discovered  at  operation  and 
repaired.  In  such  a  case  it  is  safer  to  insert  a  self-retaining  catheter 
and  put  the  patient  on  constant  drainage.  This  catheter  is  removed, 
cleaned,  boiled,  and  replaced  twice  a  day,  and  the  bladder  is  irrigated 
each  time  with  4  per  cent,  boric-acid  solution,  using  not  over  4  ounces, 
so  as  not  to  throw  much  tension  on  the  stitches.  Constant  drainage  is 
maintained  for  ten  days.  A-  small  gauze  wick  is  inserted  to  the  point  of 
injury  after  the  suture  is  completed.  The  wick  is  removed  at  the  end 
of  forty-eight  hours  and  left  out. 

When  the  injury  is  repaired  and  does  not  heal,  the  urine  is  discovered 
by  its  odor  on  removing  the  drain.  In  this  event  the  same  directions 
as  for  the  care  of  a  ureteral  fistula  are  to  be  followed.     In  any  case 


502  OPERATIONS    ON    THE    VAGINA,    UTERUS,    AND    ADNEXA 

hexamethylamin  (7I  gr.)  three  times  a  day  should  be  employed  as  a 
urinary  antiseptic. 

Thrombosis  of  the  Pelvic  and  Iliac  Veins. — This  complication  fol- 
lows hysterectomy  more  frequently  than  any  other  operation.  It  occurs 
usually  during  the  second  week  of  convalescence.  It  is  manifested 
by  swelling  of  the  thigh  and  leg,  accompanied  by  more  or  less  pain  and 
elevation  of  temperature.  The  treatment  is  elevation  and  immobiliza- 
tion by  means  of  a  pillow  and  side  splints,  such  treatment  to  be  continued 
until  all  swelling  has  disappeared.  Pain  is  to  be  controlled  by  ice-bags 
and  morphin.  Citric  acid  in  20-gr.  doses  three  times  a  day  is  considered 
theoretically  as  an  aid  in  preventing  coagulation,  and  should  be  tried. 
The  patient  must  remain  in  bed  for  one  week  after  all  swelling  has  dis- 
appeared. When  the  pillow  and  side  splints  have  been  discontinued, 
the  limb  should  be  bandaged  from  the  toes  to  the  groin  with  a  flannel  or, 
better,  an  "  Ideal "  bandage.  Some  sw^elling  of  the  ankle  while  the  pa- 
tient is  on  her  feet  will  persist  for  from  six  months  to  a  year. 

Pulmonary  Embolism. — This  occurs  as  the  result  of  dislodgment 
of  a  clot  in  the  iliac  vein,  and  generally  results  in  death.  It  may  happen 
at  any  stage  of  the  convalescence,  but  is  most  common  between  the  fifth 
and  fourteenth  days. 

Myocarditis. — Arterial  changes  and  myocardial  degeneration  are 
observed  in  a  large  percentage  of  fibroid  cases,  and  after,  operation  may 
cause  considerable  worry;  15  minims  of  tincture  of  digitalis  three  times 
a  day  should  be  given  whenever  there  is  cardiac  irregularity  after  opera- 
tion. All  cases  of  sudden  death  after  operation  which  are  not  due  to 
pulmonary  embolism  can  probably  be  ascribed  to  this  condition. 

References 

H.  A.  Kelly  and  T.  S.  Cullen,  Myomata  of  the  Uterus,  1909,  654. 

J.  G.  Clark,  Kelly-Noble,  Gynecol,  and  Abd.  Surg.,  1907,  i,  744. 

E.  Wertheim,  Zur  Frage  der  Radikaloperation  beim  Uteruskrebs,  Arch.  f.  Gynak., 
1900,  Ixi,  627. 

M.  Hofmeier,  Ueber  die  Haufigkeit  der  Thrombose  nach  gynakologischen  Opera- 
tionen  und  im  Wochenbett,  Cent.  f.  Gyn.,  1909,  xxxiii,  21. 

H.  Crouse,  Thrombi  and  Emboli,  Surg.,  Gyn.  and  Obst.,  1909,  ix,  663. 

S.  E.  Tracy,   Fibromyomata  Uteri,  Surg.,  Gyn.  and  Qbst.,  1908;  \a,  246. 

J.  A.  Sampson,  Ureteral  Fistulaj  as  Sequelae  of  Pelvic  Operations,  Surg.,  Gyn.  and 
Obst.,  1909,  viii,  479. 

CELIOTOMY  FOR  EXTRA-UTERINE  PREGNANCY 

A  patient  operated  upon  for  unruptured  tubal  pregnancy  is  to  be 
treated  exactly  as  described  for  the  after-care  of  the  lesser  operations 
upon  the  appendages.  The  complications  to  be  met  are  the  general 
ones  to  which  any  celiotomy  may  be  subject. 


CESAREAN    SECTION  503 

When  rupture  or  tubal  abortion  has  taken  place  into  a  walled-off 
cavity  before  operation,  a  wick  should  be  passed  into  this  cavity  and  a 
provisional  stitch  inserted.  The  wick  is  removed  in  forty-eight  hours 
and  the  stitch  tied.  The  case  is  now  treated  as  if  sewed  tight  in  the 
beginning. 

When  rupture  has  taken  place  into  the  general  peritoneal  cavity, 
the  ruptured  tube  and  the  broad  ligament  should  be  tied  off,  the  tube 
removed,  and  the  peritoneal  cavity  thoroughly  cleansed  of  clot.  If 
the  peritoneum  can  be  got  clean  of  practically  all  clot,  the  abdomen  may 
be  sewed  up  tight,  but  if  much  clot  remains,  and  especially  in  cases  where 
rupture  has  taken  place  several  days  before  operation,  a  gauze  wick 
should  be  passed  into  the  pelvis  behind  the  affected  broad  ligament. 
A  provisional  stitch  is  also  inserted.  At  the  end  of  forty-eight  hours 
the  wick  is  removed  and  the  stitch  tied  if  there  are  no  symptoms  of  peri- 
tonitis. 

In  the  after-treatment  of  these  cases  we  are  dealing  with  patients  in 
a  state  of  profound  anemia  and  shock,  and  immediate  treatment  should 
be  carried  out  along  the  lines  already  laid  down.  (See  Chaps.  VI 
and  VII.)  If  the  patient  passes  safely  through  the  first  five  days,  she 
is  then  in  condition  to  be  treated  according  to  the  general  rules  for  celiot- 
omy patients.  Some  form  of  iron,  preferably  Blaud's  mass,  should  be 
administered  during  the  convalescence.  The  time  of  getting  up  will 
vary  largely  with  the  degree  of  anemia.  Many  patients  may  get  up  by 
the  tenth  day,  and  all  by  the  end  of  two  weeks,  in  the  absence  of  com- 
plications. 

Complications  and  Sequelae. — Those  mostly  to  be  feared  are 
ileus  and  peritonitis.  As  these  are  treated  of  in  their  respective  chapters, 
nothing  further  will  be  said  here  concerning  them.  Other  complications 
of  anesthesia  and  celiotomy  may  occur,  and  should  be  dealt  with  by  ap- 
propriate measures. 

References 

J.  W.  Williams,  Obstetrics,  1908,  623. 

F.  S.  Newell,  Sixty  Cases  of  Extra-uterine  Pregnancy,  Boston  City  Hosp.  Reports, 
1905,  XV,  26. 

CESAREAN  SECTION 

Dressing. — The  abdomen  is  closed  without  drainage.  A  dressing 
of  sterile  gauze  is  placed  over  the  wound.  A  folded  towel  is  placed  just 
outside  of  this  above  the  fundus,  and  a  tight  swathe  applied.  A  sterile 
pad  is  placed  on  the  vulva  and  the  patient  is  put  to  bed.  The  pulse 
is  taken,  and  bleeding  from  the  vulva  looked  for  every  fifteen  minutes 
for  t\vo  hours.     The  proper  way  to  look  for  hemorrhage  is  not  to  pull 


504  OPERATIONS    OX    THE    VAGINA,    UTERUS,    AND    ADNEXA 

the  bed-clothes  down  and  look  at  the  pad,  but  to  turn  the  patient 
slightly  on  one  side  and  look  at  the  sheet  underneath.  The  blood  gravi- 
tates into  the  bed,  soils  only  the  lower  part  of  the  pad,  and  cannot  be 
seen  by  simply  separating  the  thighs  and  looking  down  from  above. 

The  vulvar  pad  is  changed  as  often  as  soiled,  and  after  each  dejection 
or  micturition  the  vulva  is  irrigated  with  sterile  water,  care  being  taken 
that  none  of  the  water  enters  the  vagina,  and  a  fresh  sterile  pad  applied. 
This  care  is  continued  to  the  tenth  day,  after  which  an  ordinar}^,  non- 
sterile  sanitary  pad  is  worn  and  the  irrigations  stopped.  After  the 
tenth  day  a  daily  mild  antiseptic  douche  may  be  given  to  clear  out  the 
lochia. 

The  wound  is  inspected  on  the  tenth  day  and  the  stitches  removed 
if  healing  has  been  normal. 

Bowels. — The  bowels  are  moved  in  forty-eight  to  sixty  hours  unless 
distention  appears  before  then. 

Diet. — Water  is  given  as  soon  as  out  of  ether.  Liquid  diet  is  started 
the  following  morning  and  soft  solids  the  second  day.  Chicken  is  al- 
lowed on  the  fourth,  and  full  diet  on  the  fifth,  day.  The  diet  must 
differ  from  that  given  other  celiotomies,  in  that  it  must  consist  largely 
of  liquids  throughout  the  convalescence  in  order  to  keep  up  a  sufficient 
secretion  of  milk. 

Bladder. — Every  possible  aid  to  natural  micturition,  such  as  hot 
applications  to  the  thighs  and  vulva,  trickling  of  hot  antiseptic  solution 
over  the  vuh-a,  and,  finally,  a  hot  enema,  must  be  tried  before  catheteri- 
zation is  allowed,  because  the  pelvic  congestion  and  increased  vascularity 
due  to  pregnancy  render  the  bladder  more  susceptible  to  infection. 
If  the  patient  has  to  be  catheterized,  hexamethylamin,  7  J  gr.  three  times 
a  day,  is  to  be  given  during  the  convalescence. 

Breasts. — The  baby  is  put  to  the  breast  the  following  day,  nursing 
on  alternate  breasts  at  four-hour  intervals  for  five  minutes  until  the 
milk  appears  in  abundance,  when  nursing  is  permitted  every  two  hours 
for  not  more  than  twenty  minutes.  The  nipples  are  washed  off  with  4 
per  cent,  boric-acid  solution  before  and  after  nursing,  and  covered  with 
clean  cold-cream  between  nursings.  If  the  nipples  become  tender,  50 
per  cent,  alcohol  is  substituted  for  the  boric-acid  solution  after  nursing 
and  nursing  is  conducted  through  a  nipple-shield.  If  the  nipples  become 
cracked,  the  cracks  are  painted  daily  with  comxpound  tincture  of  benzoin 
and  the  nipple-shield  is  used.  If  the  breasts  become  caked,  a  tight 
breast  bandage  is  applied. 

Stay  in  Bed. — The  patient  may  sit  up  on  the  twelfth,  and  get  out  of 
bed  on  the  fourteenth,  day. 


CESAREAN  .SECTION  505 

Complications  and  Sequelae. — Hemorrhage. — A  moderate  post- 
partum hemorrhage  occasionally  occurs,  and  is  rarely  severe  enough  to 
effect  the  pulse.  An  extra  dose  of  ergot  is  given  hypodermically  and  the 
hemorrhage  soon  stops.  A  serious  postpartum  hemorrhage  after  Cesar- 
ean section  is  practically  unknown.  Hemorrhage  into  the  peritoneal 
cavity  is  also  a  rarity,  since  no  arteries  are  cut  in  the  operation. 

Infection. — The  uterine  stitches  occasionally  become  infected. 
This  will  result  in  slight  foulness  of  the  pads  and  a  little  elevation  of 
temperature.  Usually  after  a  few  days  the  stitch  is  discharged  through 
the  vagina  and  the  temperature  falls. 

Septic  endometritis  is  very  rare  in  good  practice,  for  the  operation  is 
always  done  before  the  patient  has  been  long  in  labor,  and  the  patient 
is  not  examined  by  unclean  hands.  The  occurrence  of  either  of  these 
factors  ought  to  contraindicate  Cesarean  section  in  the  beginning,  or 
should  constitute  an  indication  for  a  Porro  operation  rather  than  a 
conservative  Cesarean  section.  If  septic  endometritis  does  occur,  local 
measures  are  contraindicated  on  account  of  the  wound  in  the  uterine 
wall,  and  the  treatment  should  be  directed  to  increase  the  patient's  resist- 
ance by  forced  nourishment  and  stimulation  and  by  vaccine  therapy. 
Whisky  in  half-ounce  doses  and  strychnin  in  g^-gr.  doses  every  four 
hours  may  be  given.  A  culture  may  be  taken  from  the  uterus  and  an 
autogenous  vaccine  prepared  and  used  for  treatment  under  direction 
of  one  expert  in  this  matter.  The  patient  should  be  out-of-doors  if 
possible. 

The  development  of  peritonitis  or  pelvic  abscess  should  be  met  by 
vaginal  drainage  if  possible.  If  not,  the  lower  angle  of  the  wound  may 
be  opened  and  drainage  secured  through  the  abdomen.  Further  treat- 
ment of  these  conditions  is  as  directed  in  other  chapters. 

Phlebitis. — This  is  probably  the  most  common  complication  of 
Cesarean  section.  It  usually  makes  its  appearance  in  the  second  week, 
and  is  characterized  by  a  slight  elevation  of  temperature  and  pain  and 
swelling  of  one  or,  rarely,  both  lovv^er  extremities.  The  treatment  is  rest 
in  bed  with  elevation  and  immobilization  by  a  pillow  and  side  splints. 
This  is  maintained  for  one  week  after  all  swelling  has  disappeared — i.  e., 
usually  a  period  of  six  to  eight  weeks.  Pain  is  relieved  by  ice-bags  to 
the  thigh  and  morphin.  Citric  acid  in  20-gr.  doses  three  times  a  day  is 
given  with  the  purpose  of  diminishing  the  coagulability  of  the  blood. 
The  value  of  this  measure  has  not  yet  been  finally  determined. 

Threatened  Breast  Abscess. — This  also  appears  about  the  second 
week  or  later.  It  is  characterized  by  a  sudden  rise  of  temperature, 
usually  with  a  chill  and  a  slightly  reddened  tender  lump  in  one  breast. 


5o6      OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

The  treatment  is:  first,  take  the  baby  off  the  affected  breast;  second, 
open  the  bowels  freely  with  Epsom  salt;  third,  apply  an  ice-bag  to  the 
breast;  fourth,  support  the  breast  and  the  ice-bag  by  a  bandage.  Usually 
the  temperature  begins  to  fall  within  twenty-four  hours  and  tenderness 
gradually  subsides.  The  baby  is  allowed  to  nurse  on  the  well  breast, 
and  twenty-four  hours  after  tenderness  has  disappeared  and  the  tem- 
perature has  been  normal,  may  be  put  back  on  the  affected  breast. 
A  small  lump  may  persist  for  a  time,  but  in  the  absence  of  tenderness 
or  elevation  of  temperature  does  not  contraindicate  nursing.  The 
lump  will  gradually  disappear.  If,  instead  of  quieting  down,  the 
temperature  remains  elevated  and  the  lump  becomes  more  tender, 
red,  and  indurated,  it  should  be  incised  and  the  contents  evacuated. 
The  Bier  treatment  and  vaccine  therapy  here  have  value. 

Subinvolution. — In  an  ordinary  obstetric  case  the  fundus  uteri  sinks 
below  the  symphysis  about  the  tenth  day.  After  Cesarean  section,  how- 
ever, adhesions  to  the  uterine  scar  frequently  maintain  the  uterus  in  a 
position  well  up  out  of  the  pelvis,  so  that  its  presence  on  palpation  of 
the  abdomen  does  not  in  itself  indicate  that  the  uterus  is  subinvoluted. 
The  diagnosis  is  made,  therefore,  on  the  character  of  the  lochia.  Nor- 
mally, about  the  tenth  day  the  lochia  becomes  pale  and  white.  The 
persistence  of  bloody  or  brown  lochia  after  this  period  indicates  sub- 
involution, and  should  be  treated  by  rest  in  bed  and  hot  douches  until 
the  lochia  becomes  pale. 

Othei'  Complications. — Beside  these  special  complications,  any  of 
those  common  to  all  celiotomies  may  occur — ileus,  acute  dilatation  of 
the  stomach,  etc. 

References 

C.  M.  Green,  F.  S.  Newell,  L.  V.  Friedman,  J.  R.  Torbert,  N.  R.  Mason,  R.  L.  De 
Normandie,  A  Study  of  the  First  Series  of  One  Hundred  Cesarean  Sections  Performed  at 
the  Boston  Lying-in  Hospital,  Boston  Med.  and  Surg.  Jour.,  1909,  clxi,  803. 

A.  Couvelaire,  Considerations  sur  la  technique  de  I'operation  cesarienne  conservatrice, 
Ann.  de  Gyn.,  1909,  Ixvi,  657. 

E.  Reynolds,  The  Cesarean  Section  from  the'  Standpoint  of  Personal  Experience, 
Surg.,  Gyn.  and  Obst.,  1908,  vi,  502. 

E.  P.  Davis,  The  Treatment  of  Infected  and  Complicated  Cases  of  Labor  by  Ab- 
dominal Section,  Surg.,  Gyn.  and  Obst.,  1909,  viii,  365. 

N.  R.  Mason  and  J.  T.  Williams,  The  Strength  of  the  Uterine  Scar  after  Cesarean 
Section,  Boston  Med.  and  Surg.  Jour.,  19 10,  clxii,  65. 

OTHER  OPERATIONS 

Alexanders  Operation. — See  Inguinal  Hernia. 

Atresia  of  Uterus,  Operation  for. — See  Trachelorrhaphy. 

Atresia  of  Vagina,  Operation  for. — See  Colporrhaphy. 


ECLAMPSIA  507 

Fistula,  Vesico-uterine,  Operation  for. — See  Vesicovaginal  Fistula. 

Gartner^s  Canal,  Abscess  of. — See  Vaginal  Section. 

Imperforate  Hymen,  Incision  of. — No  after-treatment  except  possible 
dilatation. 

Inversion  of  Uterus,  Celiotomy  for. — See  Celiotomy. 

Inversion  of  Uterus,  Vaginal  Operation  for. — See  Operations  upon 
Cervix  Uteri. 

Myomectomy. — See  Hysterectomy. 

Vaginal  Cysts,  Excision  of. — See  Colporrhaphy. 

ECLAMPSIA 

Eclampsia  is  a  condition  with  which  the  surgeon  may  meet  at 
any  time  when  dealing  with  pregnant  women.  Its  onset  is  usually 
characterized  by  edema  of  the  face  and  hands  and  headache.  If  the 
urine  is  examined,  as  it  should  be,  it  will  be  found  at  this  stage  to 
be  scanty  in  amount,  to  contain  from  |  to  ^  per  cent,  of  albumin,  and 
numerous  hyaline,  fine  granular,  epithelial,  and  sometimes  fatty  casts. 
Blood  is  present  in  greater  or  less  amount,  together  with  renal  epithelium. 
Dimness  of  vision  from  albuminuric  retinitis  is  the  next  symptom  to 
develop.     Epigastric  pain  is  the  forerunner  of  convulsions. 

The  typical  eclamptic  convulsion  is  of  short  duration,  seldom  lasting 
over  one  minute.  It  begins  in  the  external  eye  muscles,  extends  to  the 
face,  and  then  becomes  general.  It  is  clonic  in  character.  As  the 
convulsion  subsides,  respiration,  which  has  become  suspended  during 
its  acme,  is  reestablished,  breathing  becomes  stertorous,  and  the  cyanosis 
gradually  subsides.  The  patient  may  regain  perfect  consciousness, 
but,  as  a  rule,  passes  into  a  noisy,  restless  delirium,  which  is  interrupted 
frequently  by  further  convulsive  seizures. 

Before  the  onset  of  convulsions  or  the  development  of  eye  symptoms, 
medical  treatment  is  imperative.  The  indications  are,  first,  to  decrease 
metabolism,  especially  nitrogenous  metabolism,  to  its  lowest  possible 
state,  and,  second,  to  favor  the  elimination  of  toxins  and  waste  products. 

The  patient  is  put  to  bed  in  a  darkened  room,  on  a  liquid  diet,^ 
and  given  at  once  morphin  {\  gr.)  and  hyoscin  hydrobromid  (y^p-  gr.) 
hypodermically.  This  may  be  repeated  as  often  as  every  four  hours  if 
necessary  to  keep  the  patient  quiet. 

The  channels  of  elimination  to  be  favored  are  the  skin,  kidneys,  and 

^  Jaeger'  (Deut.  med.  Woch.,  1909,  xxxv,  No.  41)  commends  highly  the  withdrawal 
of  salt  and  restriction  of  fluids  in  banishing  edema  and  preventing  convulsions.  Milk 
contains  too  much  fluid.  Unsalted  egg  dishes  and  butter,  rice  cooked  in  milk,  sago, 
baked  potato,  puddings,  gruels  with  cream  and  sugar,  vegetables,  fruit,  and  weak  tea, 
but  no  coff'ee,  should  constitute  the  diet-list. 


5o8     OPERATIONS  ON  THE  VAGINA,  UTERUS,  AND  ADNEXA 

bowels.  The  first  is  to  be  stimulated  only  by  heaters  and  blankets. 
Hot  packs  and  hot-air  baths  have  cost  many  lives  by  their  depressing 
effect.  Pilocarpin  is  contraindicated  because  of  the  danger  of  edema 
of  the  lungs. 

The  renal  secretion  is  to  be  stimulated  by  diuretics  and  the  ingestion 
of  large  quantities  of  fluid,  provided  there  exists  no  edema.  A  2-quart 
pitcher  of  cream  of  tartar  lemonade  should  be  placed  by  the  bedside 
and  forced  upon  the  patient  until  she  has  taken  it  all.  Water  may  be 
introduced  by  rectum  or  subcutaneously.  Diuretin  (20  gr.)  in  combina- 
tion with  ID  minims  of  digitalis  every  four  hours  is  by  far  the  most 
effective  drug  for  this  purpose. 

The  bowels  should  be  moved  by  the  administration  of  i  ounce  of 
Epsom  salt. 

If,  under  this  treatment,  the  patient  shows  no  improvement  at  the 
end  of  forty-eight  hours,  she  must  be  delivered.  If  severe  eye  symptoms 
develop,  if  epigastric  pain  appears,  or  if  the  headache  and  edema  increase, 
she  must  be  delivered  at  once.  A  single  convulsion  is  an  immediate 
indication  for  delivery. 

When  a  convulsion  occurs,  a  gag  should  be  placed  between  the  teeth 
to  prevent  the  tongue  from  being  bitten.  Ether  or  chloroform  should 
never  be  given.  The  convulsion  is  too  short  to  allow  the  patient  to  inhale 
enough  to  do  any  good.  Furthermore,  respiration  is  practically  sus- 
pended at  the  acme  of  the  convulsion.  Finally,  when  the  convulsion  is 
drawing  to  a  close,  the  cyanosis  is  intense  and  the  ether  will,  of  course, 
displace  a  certain  percentage  of  the  oxygen  which  the  patient  needs  badly. 
After  the  patient  is  fully  out  of  the  convulsion,  she  should  at  once  be 
placed  under  ether  and  kept  there  to  prevent  more  convulsions  while 
preparations  are  made  for  delivery. 

After  delivery  the  stomach  is  washed  out  and  2  ounces  of  Epsom 
salt,  2  minims  of  croton  oil,  30  grains  of  diuretin,  and  10  minims  of 
digitalis  are  introduced  through  the  tube.  A  quart  of  salt  solution  is 
injected  into  the  lower  back  or  under  the  skin  of  the  abdomen.  Mor- 
phin  (^  gr.)  and  hyoscin  (-j-g-o  gr.)  are  injected  hypodermically  and 
repeated  every  four  hours  unless  the  respiration  drops  below  10.  Much 
of  the  toxin  may  be  eliminated  by  bleeding.  For  this  reason  ergot  is 
never  to  be  given.  Venesection  should  be  practised  when  there  is  a 
full,  high-tension  pulse,  i  pint  of  blood  being  withdrawn  and  replaced 
by  an  equal  quantity  of  salt  solution. 

As  soon  as  the  patient  is  able  to  swallow,  water  should  be  continually 
forced  upon  her.  Diuretin  (20  gr.)  and  tincture  of  digitalis  (lomin.)  are 
given  every  four  hours.     If  she  remains  unconscious,  they  are  introduced 


ECLAMPSIA  509 

through  the  stomach-tube,  together  with  a  pint  of  milk,  every  four  hours, 
and  I  quart  of  salt  solution  is  given  under  the  skin  at  the  same  intervals. 
If  the  bowels  have  not  been  well  moved  before  operation,  they  must  be 
started  by  a  compound  turpentine  enema  immediately,  without  waiting 
for  the  purges  to  act. 

If  the  patient  has  been  delivered  early,  recovery  usually  takes  place, 
manifested  by  returning  consciousness,  cessation  of  convulsions,  increase 
in  the  secretion,  and  diminution  of  the  pathologic  elements  of  the  urine. 
The  patient  is  to  be  kept  on  milk  diet  until  the  albumin  drops  to  ^o"  of  i 
per  cent.,  when  she  may  be  allowed  cereals,  bread,  and  toast,  but  nothing 
else  until  the  urine  has  cleared  up  entirely.  The  patient  is  usually  able 
to  get  out  of  bed  by  the  fourteenth  day.  In  mild  cases  nursing  is  allowed, 
if  there  is  any  milk,  after  the  third  day.  In  the  majority  of  these  pa- 
tients, however,  the  milk-supply  is  deficient  or  absent. 

When,  after  delivery,  the  convulsions  do  not  cease  and  the  patient 
sinks  more  deeply  into  coma,  death  may  be  predicted  with  certainty. 

Postpartum  eclampsia  is  to  be  treated  by  the  same  medical  measures 
as  described  for  the  antepartum.     These  cases  commonly  recover. 

References 

C.  M.  Green,  Notes  on  Obstetrical  Therapeutics,  Med.  News,  1903,  Iviii,  692;  Puerperal 
Eclampsia,  Trans.  Amer.  Gyn.  Soc,  1893,  xviii,  141. 
J.  W.  Williams,  Obstetrics,  1908,  518. 
J.  C.  Edgar,  Practice  of  Obstetrics,  1907,  304. 
F.  S.  Newellj  The  Treatment  of  Eclampsia,  Trans.  Amer.  Gyn.  Soc,  1905,  xxx,  307. 


CHAPTER  XLVII 

OPERATIONS  ON  THE   PENIS,  SCROTUM,  URETHRA, 
AND  PROSTATE 

General  Considerations. — In  all  postoperative  treatment  it 
behooves  the  surgeon  to  conserve  to  the  best  of  his  ability  the  function 
of  the  eliminative  organs,  for  faulty  or  disturbed  elimination  is  likely 
to  lead  to  disaster  unless  promptly  alleviated.  In  geni to-urinary  work 
the  attention  paid  to  elimination  must  be  doubled,  because  the  chief 
eliminative  system,  the  urinary  apparatus,  is  involved  by  the  operation 
and  its  function  is  already  more  or  less  impaired.  The  operation  is 
performed  with  the  intention  of  removing  the  cause  of  the  functional 
impairment;  the  after-treatment  must  strive  to  restore  natural  function 
or,  at  least,  preserve  what  is  left.  To  this  end  the  kidneys  must  be  made 
to  act  freely  and  easily;  their  product,  the  urine,  must  be  kept  or  made 
qualitatively  normal,  and  given  an  unobstructed  outlet;  existing  infec- 
tion must  be  eradicated  or  subsequent  infection  prevented;  and,  last 
and  always,  the  patient  must  be  kept  comfortable. 

Renal  Activity. — Postoperative  urinary  suppression  occurs  more 
frequently  after  genito-urinary  operations  than  after  operations  of  any 
other  sort.  Its  cause  cannot  always  be  determined,  for  infection  does 
not  explain  every  case.  Suppression  due  to  infection  will  be  discussed 
later;  the  so-called  idiopathic  or  reflex  cases  of  suppression  will  here 
be  considered.  Many  causes  are  assigned  to  explain  this  condition: 
poor  general  health,  prolonged  anesthesia  and  operation,  shock,  chronic 
nephritis,  reflex  irritation  from  the  urethra,  and  so  on.  The  thoughtful 
surgeon  operates  so  far  as  possible  only  under  the  most  favorable  condi- 
tions, often  delaying  operation  until  he  can  improve  the  patient's  general 
condition,  and  always  operating  as  rapidly  as  safety  permits;  and  never- 
theless, in  spite  of  every  care,  he  often  finds  suppression  threatening. 
It  is  a  good  plan,  therefore,  to  anticipate  trouble  and  to  institute  pro- 
phylactic treatment  from  the  start.  As  soon  as  the  patient's  stomach 
permits,  he  should  be  encouraged  to  drink  as  much  water  as  he  feels  that 
he  can  take.  A  kidney  will  excrete  a  large  amount  of  dilute  solution 
when  it  will  balk  at  concentrated  fluids.     An  excellent  device  to  increase 

510 


URINE  511 

the  intake  of  water  is  to  give  palatable  drinks;  none  excels  the  simple 
cream  of  tartar  water: 

Lemons 2 

Cream  of  tartar 2  drams 

Hot  water i  pint 

Sugar q.  s. 

Keep  a  pitcherful  at  the  patient's  elbow  and  see  that  he  drinks  long 
and  often.  He  will  take  much  more  of  this  than  of  plain  water.  More- 
over, it  has  a  slightly  diuretic  action  and  is  stimulating  to  the  kidneys. 

The  diet  should  be  liquid  for  at  least  the  first  few  days,  bland  and 
non-irritating,  with  a  low  salt  and  proteid  content,  to  spare  the  kidneys. 
Once  renal  function  is  well  established,  the  diet  may  be  gradually  in- 
creased. Meat  and  meat  soups  and  extracts  contain  too  much  protein 
compounds  to  be  safe  and  had  better  be  avoided  until  later. 

No  patient  should  be  allowed  out  of  bed  or  even  sitting  up  in  bed 
until  his  kidneys  are  acting  freely  and  easily.  Getting  patients  out  of 
bed  early  is  undoubtedly  advantageous  in  many  ways,  but  it  throws 
extra  work  on  the  heart,  and  hence  on  the  kidneys,  besides  increasing 
catabolism.  Let  the  renal  activity  be  the  indication  for  getting  genito- 
urinary cases  up. 

In  spite  of  every  care,  suppression  of  urine  may  supervene.  x\s  a 
rule,  the  warning  is  ample.  The  only  sure  way  to  detect  its  onset  is 
to  measure  the  twenty-four-hour  amount  of  urine  in  every  case.  This 
procedure  is  as  simple  as  it  is  important,  and  should  be  faithfully  car- 
ried out  until  satisfied  that  all  danger  is  past.  A  steady  decrease  in 
the  twenty-four-hour  amount  is  a  danger-signal  worth  observing.  If 
this  occurs,  the  patient  should  be  kept  in  bed  on  a  milk  diet  and  given 
alkaline  diuretics,  such  as  the  acetates,  citrates,  and  tartrates,  and 
cathartics  until  the  bowels  are  freely  open.  These  simple  measures 
suffice  to  arrest  a  certain  proportion  of  cases.  A  continued  decrease  in 
the  twenty-four-hour  amount  calls  for  free  watery  movements  and 
active  diaphoresis.  A  poultice,  which  may  be  made  of  digitalis  leaves, 
over  the  kidneys  acts  surprisingly  well  in  promoting  excretion  of  urine. 
All  the  usual  treatment  for  acute  renal  disease  must  be  promptly  given — 
the  case  is  desperate  and  calls  for  desperate  measures. 

Urine. — Most  genito-urinary  cases  coming  to  operation  are  passing 
urine  which  possesses  pathologic  constituents.  In  the  majority  of  cases 
the  urine  as  it  leaves  the  kidneys  is  nearly  normal;  it  is  the  pathologic 
process  lower  down  in  the  urinary  tract  that  changes  its  character. 
Infection  anywhere  along  the  urinary  tract  adds  to  the  urine  pus,  bac- 


512     OPERATIONS    ON    PENIS,    SCROTUM,    URETHRA,    AND    PROSTATE 

teria,  blood,  and  local  tissue-cells.  Mechanical  obstruction  causes 
stasis  and  retention  of  urine,  which  gives  rise  to  anatomic  changes  in 
the  urinary  tract,  with  concomitant  alterations  of  function.  The  retained 
urine  decomposes  and  ferments;  a  catarrhal  condition  of  the  mucosa 
results,  with  its  profuse  discharge  of  mucus.  Such  a  condition  readily 
favors  infection,  which  sooner  or  later  is  bound  to  supervene.  The 
operation  supposedly  removes  the  cause  for  the  pathologic  state  of  the 
urine,  but  the  process  may  have  gone  on  for  a  sufficient  length  of  time 
to  cause  tissue  changes  which,  in  turn,  serve  to  perpetuate  the  abnormal 
constituents  of  the  urine. 

As  an  infected  or  decomposed  urine  flowing  over  an  operative 
wound  is  a  real  danger,  the  sooner  the  abnormal  urine  can  be  cor- 
rected, the  better.  To  this  end  the  free  diuresis  already  advocated 
serves,  by  thoroughly  washing  out  the  urinary  tract  and  by  causing 
increased  frequency  of  urination,  to  prevent  retention.  In  addition, 
as  a  urinary  disinfectant,  hexamethylamin  (urotropin),  y^-  gr.  three 
times  a  day  after  meals,  should  be  given  as  soon  as  the  stomach 
will  tolerate  it.  Owing  to  the  slight  renal  irritation  which  this  drug 
causes,  it  is  well  to  omit  it  every  fourth  day.  Continue  the  drug  until 
the  urine  becomes  normal.  If  the  urine  remains  foul  in  spite  of  the 
antiseptic  drugs  and  cystitis  is  present,  wash  out  the  bladder  with  some 
mild  antiseptic,  such  as  boric  acid.  Strong  antiseptics  may  give  rise 
to  pain  and  make  the  cystitis  worse.  If,  however,  there  is  no  improve- 
ment, a  dilute  solution  of  silver  nitrate  may  be  used  (i :  4000),  increasing 
gradually  up  to  i  :  800.  In  washing  out  the  bladder  only  2  or  3  ounces 
of  fluid  must  be  injected  at  a  time  and  allowed  to  run  out  again,  this  being 
repeated  until  the  solution  comes  back  clear.  The  fluid  should  have  a 
temperature  of  about  100°  F.  The  best  apparatus  is  a  soft-rubber 
catheter  attached  to  a  funnel,  or  a  glass  irrigating  nozzle  connected  with 
a  fountain  syringe.  (See  also  Chap.  XIV,  p.  133.)  If  the  urine  is 
strongly  alkaline,  benzoate  of  ammonium  can  be  given  in  lo-gr.  doses; 
if  strongly  acid,  bicarbonate  of  soda  in  10-  to  20-gr.  doses  should  be  used. 

Locally,  much  can  be  done  to  improve  the  urine.  The  field  of 
operation  is,  as  has  already  been  stated,  commonly  the  seat  of  a  low- 
grade,  but  nevertheless  persistent,  infection,  which  it  is  the  object  of 
the  operation  to  relieve,  and  that,  too,  in  the  presence  of  infected  urine. 
As  Dr.  Francis  S.  Watson  has  epigrammatically  expressed  it,  "Asepsis 
in  genito-urinary  work  is  drainage."  All  operative  wounds,  except 
in  the  rare  clean  cases  where  there  is  a  fair  chance  for  first  inten- 
tion, must  heal  from  the  bottom  by  granulation.  There  must  be  no 
chance  for  pocketing  of  infective  material;   no  blind  recesses  to  harbor 


URINE  513 

small  collections  of  urine;  and,  so  far  as  possible,  no  uphill  drainage. 
Thorough  frequent  irrigations  of  all  wounds  with  mild  antiseptics  serve 
to  keep  them  clean  and  free  of  debris;  gauze  packs  and  wicks  rarely 
stay  placed  in  wounds  discharging  urine,  and  when  they  do,  become 
plugs  rather  than  drains.  In  many  cases  for  the  first  few  days  the  urine 
escapes  by  preference  through  the  operative  wound,  which  must,  there- 
fore, be  kept  unobstructed. 

Unobstructed  Natural  Outlet  for  Urine. — Many  geni to-urinary  cases 
come  to  operation  for  the  relief  of  urinary  obstruction.  The  operation 
relieves  the  difficulty,  often,  of  necessity,  by  making  a  temporary  artificial 
outlet  for  the  urine  as  well  as  removing  the  obstruction  in  the  natural 
outlet.  During  the  process  of  healing,  therefore,  the  natural  passages 
must  be  kept  wide  open.     Failure  in  this  regard  may  mean  that  the 


Fig.  168. — Method  of  Urethral  Oil-injection  Before  Certain  Procedures. 

operation  is  a  failure;  and  in  those  cases  where  an  artificial  outlet  has 
been  made,  this  oudet  will  persist  indefinitely  as  a  urinary  sinus  so  long 
as  obstruction  to  the  natural  outlet  exists.  The  means  of  keeping  the 
urinary  passages  open  will  be  taken  up  in  detail  later. 

/w/ec/icw.— Existing  infection  is  best  combated  by  the  free  diuresis, 
competent  drainage,  frequent  irrigation,  and  administration  of  urinary 
antiseptics  already  described.  The  same  measures  serve  also  to  prevent 
the  occurrence  of  infection.  In  addition,  the  operative  wound  should 
be  kept  covered  with  a  sterile  dressing,  frequently  changed.  Infection 
once  started  calls  for  more  frequent  irrigations  and  the  relentless  use 
of  the  knife.  All  the  tissues  must  be  laid  wide  open.  Hot  soaks  in  a 
sitz-bath  are  invaluable  and  comforting.  Uncontrolled  infections  have 
a  direful  tendency  to  spread  upward  along  the  urinary  tract,  where  the 
difficulty  of  combating  them  is  doubled. 
33 


514     OPERATIONS    ON    PENIS,    SCROTUM,    URETHRA,    AND    PROSTATE 

Comfort  of  the  Patient. — Hardly  anything  more  uncomfortable 
can  be  imagined  than  the  postoperative  genito-urinary  case,  with  his 
urine  constantly  dribbling  away,  beyond  his  control,  keeping  his  dressing 
wet  and  diffusijiig  a  rank  odor  of  stale  urine.  Nothing  can  be  too  trivial 
to  perform  which  will  add  an  atom  of  comfort.  Use  large  absorbent 
dressings  and  change  them  every  hour  if  necessary.  A  little  menthol 
or  charcoal  sprinkled  in  the  dressing  will  disguise  or  absorb  the  odor 
markedly.  Keep  the  edges  of  the  wound  and  the  surrounding  skin 
smeared  with  zinc-oxid  ointment  to  protect  the  skin,  which  easily  becomes 


Fig.  169. — Convenient  Method  for  Perineal  Dressings. 

red,  burning,  and  itching  from  the  constant  bath  of  urine.  Bed-sores 
form  quickly  if  the  patient  lies  for  hours  in  a  wet  dressing  or  a  wet  bed, 
and  are  difficult  to  heal. 


CIRCUMCISION 

The  method  of  dressing  whereby  a  roll  of  gauze  is  tied  along  the 
wound  by  the  long  ends  of  the  interrupted  catgut  sutures  is  ingenious, 
but  is  not  to  be  commended.  •  This  ring  of  gauze  gets  heavy  and  sti£f 
with  blood,  gets  foul  in  odor,  and  gets  loose  here  or  there  irregularly, 
according  as  one  or  another  stitch  gives  way.  Interrupted  catgut  stitches 
should  be  used,  cut  short. 


MEATOTOMY  515 

At  the  end  of  operation  on  an  adult  the  glans  should  be  covered 
with  a  plentiful  mass  of  eucalyptus  vaselin  (5  per  cent.),  the  region  of 
the  wound  bandaged  with  a  few  turns  of  some  kind  of  chemical  gauze, 
held  in  place  by  a  narrow  adhesive  strip,  barely  tight  enough  to  hold 
it.  An  infant  needs  no  fixed  dressing.  A  mass  of  absorbent  cotton 
should  now  envelop  the  organ,  and  the  whole  be  held  up  by  a  T-bandage 
or  some  other  modification  of  the  jockey-strap.  After  each  micturition 
more  vaselin  should  be  put  on.  The  dressing  should  be  entirely  changed 
at  least  once  in  twenty-four  hours. 

For  the  first  twenty-four  hours  the  less  the  patient  is  on  his  feet  the 
better.  Sodium  bromid  (40  gr.)  in  a  glass  of  water  should  be  given  to 
adults  at  bedtime  the  first  three  nights  to  avoid  painful  erections. 

Complications  and  Sequelae.— Hemorrhage  from  a  retracted 
vessel  may  take  place,  even  to  an  alarming  amount,  in  children. 
The  bleeding  point  must  be  found  and  tied.  Sometimes  blood  collects 
between  the  layers  in  the  form  of  a  hematoma.  This  should  be  opened 
and  evacuated  under  aseptic  precautions,  otherwise  the  clot  is  likely  to 
become  septic  and  cause  sloughing  of  the  flap. 

Sepsis  always  appears  to  a  mild  degree.  A  considerable  amount 
of  swelling  may  be  expected,  and  calls  for  no  treatment  unless  accom- 
panied by  much  pain.  In  this  case  the  organ  may  be  soaked  in  salt 
and  citrate  or  warm  myrrh  wash.  Spots  of  foul-smelling  gangrene 
near  the  stitches  are  touched  with  carboHc  acid  followed  by  alcohol. 

If  the  skin-flap  has  been  cut  too  short,  erections  will  be  painful  until 

the  scar  has  stretched. 

MEATOTOMY 

This  operation  is  usually  done  as  a  preliminary  step  to  further  opera- 
tion on  the  urethra.  Nevertheless,  it  requires  some  attention.  The 
operation  leaves  a  wound  which  is  washed  with  urine  at  every  micturi- 
tion. There  is  scarcely  any  danger  from  absorption  in  so  small  an 
open  wound,  but  a  concentrated  urine  on  the  raw  surface  will  smart  and 
burn.  It  will  add  greatly  to  the  patient's  comfort,  therefore,  if  vaselin 
be  kept  thickly  spread  in  and  around  the  meatus  and  if  the  patient  be 
given  alkaline  diuretics  by  mouth  for  the  first  few  days.  Any  dressing 
after  the  first  bleeding  has  ceased  is  superfluous.  Forty-eight  hours 
after  operation  pass  a  sound  (-No.  30  French)  through  the  meatus  and 
repeat  every  other  day  until  no  bleeding  follows. 

Meatotomy  exactly  in  the  middle  line  I  have  known  in  two  instances 
to  destroy  sexual  appetite.  If  the  incision  is  made  slightly  to  one  side 
of  the  frenum,  there  need  be  no  apprehension  on  this  score. 


5l6     OPERATIONS    ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 

HYPOSPADIAS 

The  after-care  of  this  operation  calls  for  the  greatest  patience  and 

attention  to  details.     The  soft-rubber  draining  catheter  should  be  kept 

in  position  a  week  if  possible.     As  a  rule,  however,  the  bladder  of  the 

child  is  intolerant  of  a  catheter  more  than  three  days.     At  the  end 

of  that  time,  therefore,  it  is  frequently  necessary  to  remove  the  catheter 

and  keep  it  in  the  new  urethra  only.     The  catheter  must  be  taken  out, 

cleaned,  and  passed  into  the  bladder  to  draw  the  urine  every  three  or 

four  hours.     Complete  union  of  the  full  length  of  the  wound  is  hardly 

to  be  expected  at  the  first  operation,  but  at  each  operation  some  gain 

should  be  made.     The  wound  must  be  dressed  two  or  three  times  a  day, 

iodoform  being  invaluable. 

EPISPADIAS 

This  rare  operation  presents  no  questions  in  after-treatment  not  cov- 
ered in  Hypospadias  {supra) .  In  each  of  these  operations  two  objects  are 
to  be  constantly  in  mind:  first,  that  the  external  wound,  the  site  of  the 
old  urethral  opening,  heals;  second,  that  the  new  urethra  be  kept  patent. 
The  external  wound  is  to  be  treated  aseptically,  like  any  clean  wound. 
This  wound  will  heal  without  the  formation  of  a  sinus  provided  the  new- 
urethra  be  kept  patent.  The  slightest  narrowing  at  any  point  endangers 
the  breaking  down  of  the  operative  wound,  with  the  persistence  of  a 
troublesome  urinary  sinus.  Sounds  every  other  day,  therefore,  are  the 
only  remedy.  After  two  weeks  the  interval  between  the  passage  of 
sounds  may  be  lengthened  to  twice  a  week,  then  once  a  week,  then  once 
in  two  weeks,  and  so  on,  omitting  them  entirely  at  the  end  of  a  year. 

HYDROCELE 

Treated  by  Injection. — The  use  of  iodin  or  plain  phenol  has 
fallen  into  disuse.  Occasionally,  injection  of  a  mixture  of  equal  parts 
of  phenol,  alcohol,  and  glycerin  is  used.  The  fluid  is  drained  off  with 
a  medium-sized  trocar,  and  from  i  to  3  drams  of  this  mixture  are 
injected  in  through  the  trocar  still  in  place.  The  end  of  the  trocar  is 
now  covered  with  the  finger,  and  the  scrotum  gently  manipulated  to 
bring  the  fluid  into  contact  with  all  the  folds  of  the  sac.  At  the  end  of 
about  four  minutes  whatever  fluid  will  run  out  is  withdrawn,  and  the 
cannula  wound  is  sealed  with  collodion. 

Within  two  or  three  hours  there  are  heat,  pain,  and  swelling — a  con- 
dition of  acute  hydrocele.  The  patient  should  be  kept  reclining  twenty- 
four  hours.  Ice  should  not  be  used  until  it  is  estimated  that  enough 
inflammation  has  ensued  to  destroy  the  membrane  lining  the  sac.  The 
swelling  usually  lasts  three  to  four  weeks. 


VARICOCELE 


517 


After  ^Excision  of  the  Sac. — The  operation  here  assumed  is 

that  in  which  the  major  part  of  the  sac  is  removed,  leaving  only  enough 

margin  on  each  side  of  the  epididymis  to  fold  back  and  be  sewed  over 

that   region   and   the   cord.     The   patient   should  be  in  bed  at  least 

three  days,  the  scrotum  well  supported  upon  the  pubes.     Silk,  linen, 

or  catgut  sutures  in  the  skin  are  preferable  to  the  stiff  silkworm  gut,  for 

obvious  reasons.     Hematoma  and  sepsis  are  to  be  watched  for.     The 

wound  should  be  healed  in  ten  days.     A  suspensory  should  be  worn  for 

two  months. 

VARICOCELE 

It  is  assumed  that  the  operation  which  has  been  done  is  that  in  which 
a  section  of  the  varicose  cord,  excluding  the  vas  and  its  vessels,  has  been 
excised,  and  the  cut  ends  tied  together  to  bring  the  testis  into  normal 
position.  A  dressing  should  be  applied  similar  to  that  for  inguinal 
hernia,  taking  particular  care  that  the  scrotum  is  efficiently  supported. 
Uncomplicated,  the  scrotal  wound  should  heal  as  any  clean  wound. 
The  patient  may  get  up  at  the  end  of  a  week,  the  scrotum  being  supported 
for  two  months  in  a  properly  adjusted  suspensory. 

Complications  and  Sequelae. — Hemorrhage. — Bleeding  may 
occur  in  the  scrotum  from  the  slipping  of  ligatures  or,  a  still  more  serious 
matter,  the  proximal  end  of  the  cut  cord  has  been  known  to  retract 
through  the  canal  and  bleed  into  the  abdominal  cavity.  This  possibility 
should  be  in  mind,  and  signs  of  hemorrhage  in  the  scrotum  or  of  internal 
hemorrhage  should  be  met  by  an  immediate  secondary  operation,  opening 
up  the  region  thoroughly  until  the  bleeding  end  is  found  and  secured. 

Atrophy  of  the  Testis. — This  may  occur  even  though  the  vas  has  not 
been  injured,  and  a  statement  of  its  possible  occurrence  must  be  made 
to  the  patient  before  operation.     It  calls  for  no  treatment. 

Gangrene  of  the  Testis. — This  will  occur  if  the  vas  is  cut  or  if  every 
artery  is  cut,  though  it  is  very  difficult  to  cut  all  the  vessels  without 
injuring  the  vas,  or  it  may  be  the  result  of  a  tight  or  improperly  applied 
bandage.  When  this  process  begins,  the  wound  opens  and  the  sloughing 
testicle  presents  itself.  It  may  be  cut  away  as  fast  as  it  extrudes,  \^-ithout 
anesthesia,  or,  to  save  time,  if  it  is  evident  that  complete  death  of  the 
testis  is  unavoidable,  castration  may  be  done  at  once.  Radical  opera- 
tion should  not  be  hurried  into,  however,  for,  after  slough  of  all  save 
the  skin  and  the  testis,  the  testis  may  remain  viable  and  the  skin-edges 
be  brought  gradually  together  over  it  by  means  of  adhesive  strips,  and 
give  finally — so  great  is  the  adaptability  of  the  scrotal  tissues — a  good 
cosmetic  result. 


5l8     OPERATIONS    ON    PENIS,    SCROTUM,    URETHRA,    AND    PROSTATE 

UNDESCENDED  TESTIS 

Unless  the  cord,  when  freed  by  dissection  or  elongated  by  dissecting 

away  its  veins  and  unfolding  the  kinks,  is  long  enough  to  allow  the  testis 

to  remain  in  the  scrotum  without  being  held  under  considerable  tension, 

the  operation  will  ultimately  fail,  the  testis  being  actually  drawn  back 

into  the  canal  or  drawn  up  so  tightly  against  the  external  ring  as  to 

cause  constant  and  unbearable  discomfort.     Wherever  the  testis  rests 

without  undue  tension  within  the  scrotum,  there  are  no  special  directions 

in  the  care  of  the  wound,  which  resembles  that  after  inguinal  hernia. 

Special  pads  or  other  apparatus  for  holding  the  testis  down  are  of  no 

value.     A  testis  which  has  long  been  retained  is  likely  to  have  lost  its 

power  of  functioning  on  account  of  pressure  atrophy,  so  that  this  operation 

performed  in  an  adult  is  not  likely  to  have  any  effect  on  a  preexisting 

sterility. 

CASTRATION 

The  wound  after  this  operation  calls  for  no  special  treatment.  Wounds 
of  the  scrotum,  on  account  of  the  folds  in  the  skin,  are  liable  to  sepsis. 
The  stump  of  the  cord,  unless  the  precaution  is  taken  of  sewing  it  into 
the  abdominal  ring,  may  retract  and  bleed.  Hernia  is  likely  to  make  its 
appearance  after  castration, 

INTERNAL  URETHROTOMY 

As  soon  as  the  operation  is  completed,  irrigate  the  bladder  and 
urethra  thoroughly  with  hot  boric-acid  solution  (2  per  cent.).  Do  not 
tie  a  catheter  into  the  anterior  urethra  unless  there  is  considerable 
hemorrhage.  Put  the  patient  to  bed,  and  start  on  cream-of-tartar 
water  and  urotropin  as  soon  as  the  stomach  permits.  He  is  not 
let  up  until  the  kidneys  are  actively  secreting.  Immediately  after  the 
first  urination  following  operation  irrigate  the  urethra  through  a  Valen- 
tine nozzle  or  one  of  its  modifications  with  warm  silver  nitrate  solution 
(1:2000).  Forty-eight  hours  after  operation  irrigate  the  urethra  again 
with  the  same  solution;  pass  sounds  or  the  Kollmann  dilator  into  the 
bladder  to  maintain  the  caliber  to  which  the  urethra  has  been  cut,  then 
irrigate  again.  Repeat  the  irrigation  and  sounds  every  other  day  until 
no  bleeding  follows.  This  indicates  that  the  wound  has  healed,  and  its 
surface  is  covered  with  mucous  membrane.  Thereafter  pass  sounds 
twice  a  week,  then  once  a  week,  gradually  lengthening  the  interval,  and 
omitting  them  entirely  at  the  end  of  a  year. 

Frequently  repeated  irrigation  as  described  above  keeps  the  urethra 
clean,  combats  any  tendency  to  infection,  and  does  more  to  prevent 
reflex  urethral  chill  than  all  other  measures.    When  least  expected,  the 


EXTERNAL   URETHROTOMY 


519 


passage  of  a  sound  will  cause  a  chill,  followed  by  a  rise  of  temperature 
and  considerable  exhaustion,  due  to  reflex  causes.  Why  this  should 
occur  is  not  to  be  satisfactorily  explained,  but  that  it  does  occur  is  an 
estabhshed  fact,  most  disquieting  to  the 
patient.  (See  Chap.  XTV,  p.  140.)  A 
warm  drink  and  heaters  will  encourage 
him  to  regard  the  chill  as  a  small  matter. 
Morphin  usually  acts  well.  A  single  chili 
is  no  cause  for  alarm,  but  repeated  chills 
after  the  passage  of  sounds  are  likely  to 
mean  threatened  infection.  Keep  such  a 
patient  in  bed  under  regular  constitutional 
treatment.  Fortify  the  kidneys  with 
diuretics  and  irrigate  the  urethra  after 
each  urination.  Watch  carefully  for  col- 
lections of  pus  round  the  penile  urethra 
and  in  the  perineum  and  open  them 
promptly. 

Complications  and  Sequelae. — 
This  operation  is  rarely  practised  by 
American  surgeons  because  of  the  dangers 
of  hemorrhage,  perineal  abscess,  extrav- 
asation of  urine,  and  even  septicemia. 
Hemorrhage  after  internal  urethrotomy 
may  be  met  by  tying  in  a  maximum  sized  soft  catheter,  with  compres- 
sion against  the  catheter  from  without.  Since  the  other  complications 
are  to  be  met  only  by  a  perineal  section,  we  then  have  the  after-con- 
ditions of  external  urethrotomy.  As  a  matter  of  practice  also  there  is 
no  time  saved  by  an  internal  operation  over  the  external  one. 


Fig.  170. — KoLLMANN   Deep   Urethrai, 
Dilator,  with  Rubber  Covering. 


EXTERNAL   URETHROTOMY 

This  is  the  operation  of  choice  for  deep  strictures,  and  the  only  one 
for  impassable  strictures.  Immediately  after  the  operation  irrigate  the 
bladder  and  whole  urethra  with  hot  boric-acid  solution  (2  per  cent.). 
All  surgeons  agree  that  after  this  operation  a  catheter  must  be  tied-  into 
the  bladder,  but  are  about  evenly  divided  as  to  whether  it  should  be 
tied  in  through  the  perineum  or  through  the  urethra.  In  either  case  use 
a  soft-rubber  catheter  (No.  30  French).  Only  as  much  of  the  catheter 
as  contains  the  fenestrum  should  project  into  the  bladder.  As  a  pre- 
caution against  plugging,  an  extra  window  may  be  cut  in  the  catheter 
opposite  and  proximal  to  the  other. 


520     OPERATIONS   ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 

To  hold  a  catheter  in  the  perineum  use  a  Watson  perineal  button  of 
hard  rubber  (Fig.  171).  With  the  catheter  in  place  and  the  wound 
covered  with  sterile  gauze,  pass  the  large  central  hole  of  the  button 
snugly  over  the  catheter  and  against  the  perineum.  Through  each  pair 
of  lateral  holes  in  the  button  pass  a  strip  of  tape.  Pass  two  ends  of  the 
tapes  backward  and  upward  over  the  buttocks;  the  other  two  forward 
and  upward  over  the  pubes;  tie  all  the  ends  together  over  the  symphysis 
just  above  the  root  of  the  penis.  The  catheter  must  fit  the  button 
closely  or  it  will  not  stay  in  place.  Place  a  large  dressing  on  the  peri- 
neum perforated  for  the  catheter  and  held  in  position  by  a  T-bandage. 
A  piece  of  rubber  tubing,  one  half  split  into  four  tails,  may  be  used  in- 
stead of  the  button. 


Fig.  171. — Watson's  Perineal  Button  of  Hard  Rubber  for  Retaining  Soft-rubber  Catheter. 
The  tapes  are  strung  through  holes  in  edge  of  button,  which  is  then  threaded  on  catheter.     Buttons  are  made 

for  each  size  catheter. 


As  soon  as  the  patient  is  in  bed,  fasten  to  the  open  end  of  the  catheter 
with  a  piece  of  glass  tubing  a  long  rubber  tube  which  leads  to  a  bottle 
beneath  the  bed  (Fig.  183).  A  loop  of  the  tube  should  be  held  by  a  safety- 
pin  to  the  under  sheet  to  allow  slack  for  the  patient  to  roll  round  in  bed. 
If  the  bottle  be  tied  to  the  side  of  the  bed,  there  will  be  less  danger  of  dis- 
arranging the  apparatus  should  the  bed  be  carelessly  moved.  As  soon 
as  the  bladder  fills  the  urine  flows  out  into  the  tube,  spontaneously  estab- 
lishing siphon  drainage.  At  the  end  of  forty-eight  hours  dress  the  perineal 
wound  and  remove  the  catheter-.  Apply  a  large  absorbent  dressing  and 
change  it  as  often  as  it  becomes  saturated  with  urine.  For  the  first 
few  days  all  the  urine  will  escape  through  the  perineum,  perhaps  in- 
voluntarily. Twenty-four  hours  after  the  catheter  has  been  removed 
irrigate  the  bladder  and  urethra  with  hot  silver  nitrate  solution  (i :  2000), 


EXTERNAL   URETHROTOMY  52 I 

pass  sounds  up  to  the  size  of  the  normal  urethra,  then  irrigate  again. 
Repeat  the  irrigations  and  sounds  every  other  day  until  bleeding  ceases; 
then  twice  a  week,  as  described  under  Internal  Urethrotomy. 

If,  as  is  preferable,  the  catheter  is  to  be  tied  in  through  the  urethra, 
it  is  held  in  place  by  any  one  of  several  ways.  The  best,  from  the  point 
of  view  of  cleanliness  and  efficiency,  is  as  follows:  Two  pieces  of  l-in. 
tape  8  in.  long  are  fastened  by  their  middle  with  a  safety-pin  through 
the  tape  and  catheter  exactly  at  the  meatus.  The  ends  of  the  tape  are 
then  passed  down  each  side  of  the  penis,  and  are  held  there  by  two 


Fig.  172. — Catheter  Held  in  Penis. 

Two  pieces  of  cotton  tape  are  pinned  at  their  middle  by  a  safety-pin  to  the  appropriate  point  on  the  catheter. 
The  fovir  ends  are  carried  back  to  the  root  of  the  penis,  and  a  narrow  strip  of  adhesive  plaster  is  bound  loosely 
(to  allow  for  future  congestion)  about  penis  and  tapes.  Over  this  strip  the  ends  are  turned  back,  and,  to  prevent 
slipping,  bound  down  by  a  second  circular  turn  of  adhesive.  A  third  collar  of  adhesive  is  applied  just  behind 
the  corona.  During  the  application  the  skin  of  the  penis  should  be  kept  on  a  stretch,  to  prevent  any  play  of  the 
catheter  in  and  out. 

circular  turns  of  zinc-oxid  plaster  about  h  in.  wide.  By  this  method 
the  glans  is  free  from  any  permanent  application  and  remains,  there- 
fore, unirritated.  This  retaining  apparatus  can  be  readily  changed, 
if  need  be,  without  disturbing  the  catheter  (Fig.  172). 

As  soon  as  the  patient  is  in  bed  establish  siphon  drainage,  as  described 
above.  This  method,  if  carefully  applied  and  cared  for,  drains  the 
bladder  as  well  as  the  perineal  catheter  does,  and,  in  addition,  di\-crts 
the  stream  of  urine  from  the  wound.  On  the  other  hancl  it  is  not  as 
comfortable  for  the  patient  and  is  often  troublesome  to  care  for.  Oc- 
casionally  the    catheter   excites   such   spasmodic    contractions   of   the 


52  2      OPERATIONS    ON   PENIS,    SCROTUM,    URETHRA,    AND    PROSTATE 

urethra  that  the  catheter  is  buckled  completely  out  in  spite  of  the  fact 
that  the  retainer  tapes  hold  firmly,  and  the  attempt  to  keep  it  in  place 
must  be  abandoned.  Leave  the  catheter  in  situ  if  possible  four  to  seven 
days.    By  that  time,  often  before,  a  seropurulent  discharge  \\\\\  be  found 


Fig.  173. — Passing  a  Sound. 
Penis  is  manipulated  as  little  as  possible. 


oozing  from  the  urethra  round  the  catheter.  This  secretion  is  the  re- 
action of  the  urethra  against  the  foreign  body  which  it  contains.  If 
the  discharge  becomes  profuse,  remove  the  catheter  promptly,  but  wait 
until  the  fifth  day  if  possible.     Twenty-four  hours  after  removing  the 


Fig.  174. — Passing  a  Sound. 
Beginning  introduction. 


catheter  irrigate  and  sound  the  urethra  as  above.  Rarely  by  the  fifth 
day  is  the  perineal  wound  found  so  far  healed  as  to  prevent  the  escape  of 
some  urine  through  it  during  the  act  of  micturition. 

After  the  removal  of  the  catheter,  irrespective  of  the  way  in  which  it 


EXTERNAL   URETHROTOMY 


523 


had  been  worn,  every  attention  must  be  given  to  healing  the  perineal 
wound  and  keeping  the  urethra  open.  At  first  it  is  not  unusual  to  find 
that  there  is  some  loss  of  control  of  the  sphincter,  allowing  the  urine  to 
dribble  away  involuntarily.     This  loss,  as  a  rule,  is  regained  a  day  or 


Fig.  175. — Passing  a  Sound. 
The  handle  is  so  gently  elevated  that  the  instrument  finds  its  way  into  the  urethra  by  its  own  weight. 

two  after  the  catheter  is  removed.  About  a  week  after  the  operation 
the  patient  begins  to  pass  some  urine  through  his  penis.  As  the  perineal 
wound  heals,  more  and  more  urine  comes  through  the  penis,  until,  finally, 
it  all  comes,  that  way.     Occasionally  after  a  day  or  so  without  perineal 


Fig.  176. — Passing  a  Sound. 
Demi-tour  de  maitre,  carrying  the  tip  to  the  pubic  arch. 

leakage  small  amounts  of  urine  again  escape  from  the  perineum.  This 
need  offer  no  cause  for  alarm,  provided  the  urethra  is  well  dilated,  for 
it  soon  ceases.  The  patient  can  materially  help  to  send  his  urine  through 
his  penis  if,  during  the  act  of  micturition,  he  will  stand  perfectly  upright 


524     OPERATIONS    ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 

and  press  his  thighs  closely  together  or  stand  cross-legged.  As  long  as 
any  urine  escapes  through  the  perineum  the  dressing  should  be  changed 
after  every  urination.  The  patient  can  be  taught  to  attend  to  this  matter 
himself. 

The  secret  of  success  lies  in  thorough  and  persistent  use  of  sounds. 
The  urethra  must  be  kept  stretched  up  to  normal  caliber.  The  slightest 
narrowing  is  enough  to  prevent  the  healing  of  the  perineal  wound  and 
to  perpetuate  a  ijrmary  sinus.  Any  tendency  toward  contraction  must 
be  combated  by  more  frequent  sounding  than  that  advised  above. 
Leaving  a  sound  in  the  urethra  for  five  or  ten  minutes  is  often  efficacious 
in  overcoming  a  tendency  to  contraction.  It  is  hard  to  convince  patients 
of  the  necessity  for  the  prolonged  use  of  sounds;  failure  to  do  so  often 


Fig.  177. — Passing  a  Sound. 
Demi-tour  completed.     Carrying  the  tip  under  the  pubic  arch. 

means  an  unsuccessful  operation  and  sometimes  a  urinary  sinus  in  the 
perineum. 

However  dirty  the  bladder  before  operation,  the  short  period  of 
drainage  and  unobstructed  outflow  suffice  to  clean  it  up  surprisingly 
well.  If  it  is  thought  necessary,  the  bladder  may  be  irrigated  daily  or 
oftener  through  the  retained  catheter;  free  diuresis  and  urinary  anti- 
septics complete  the  cure. 

Some  cases  of  long-standing  stricture  are  complicated  by  such  con- 
ditions as  extravasation  of  urine,  peri-urethral  abscess,  or  a  watering- 
pot  perineum  full  of  scar  tissue'.  In  any  case,  no  amount  of  good  after- 
treatment  will  correct  or  make  up  for  an  inefficient  operation.  In 
short,  the  stricture  must  have  been  fully  divided,  the  draining  catheter 
must  be  extended  well  into  the  bladder,  and  the  perineal  wound,  how- 
ever small,  must  be  a  triangle,  its  base  at  the  skin.     That  is  to  say. 


EXTERNAL    URETHROTOMY  525 

whatever  drainage  there  is  must  be  efficient.  In  uncompHcated  and 
simple  strictures  the  perineal  wound  may  be  made  very  small,  may  be 
drained  with  small  strands  of  iodoform  gauze,  and,  if  the  urethra  has 
been  sewed  over  the  catheter,  as  is  sometimes  advisable,  the  wound  may 
never  leak  urine.  In  cases  with  abscess  or  extravasation,  however,  the 
wound  should  be  large,  and  packed  lightly  with  enough  iodoform  gauze 
to  maintain  the  wound  as  a  single  cavity  for  a  time;  the  dressing  should 
be  changed  once  or  twice  in  twenty-four  hours,  so  as  to  keep  it  sweet. 

For  the  frightfully  septic  cases,  where  multiple  incisions  of  buttocks 
and  scrotum  have  been  necessary,  dressings  every  three  hours  may  help : 
remove  all  the  packing,  sponge  out  the  depths  of  the  wound  with  chlorin- 
ated soda  (i :  800),  pack  lightly  with  iodoform  gauze,  apply  a  large  salt 
and  citrate  poultice,  with  a  many-tailed  bandage,  and  place  outside 


Fig.  178. — Passing  a  Sound. 
Handle  gently  depressed  in  the  median  line  as  the  instrument  traverses  the  membranous  portion  and  enters  the 

bladder.   . 

all  this  dressing  a  constantly  refilled  hot-water  bottle,  taking  great  care 
that  no  burn  shall  occur.  When  the  wound  (or  wounds)  is  a  single 
clean  cavity  wherein  there  seems  to  be  no  danger  of  side  pockets  forming, 
all  packing  or  drainage  should  be  left  out;  the  wound,  however,  should 
be  repeatedly  cleaned  mechanically  and  dressed  with  some  stimulant, 
such  as  balsam  of  Peru. 

Complications  and  Sequelae. — Plugging  of  catheter  with  blood 
or  pus  may  take  place  at  any  time.  The  danger  of  this  is  largely  averted 
if,  before  insertion,  as  already  described,  an  extra  window  is  cut  in  the 
end  of  the  catheter  opposite  the  usual  opening  and  about  \  in.  higher. 
If  the  catheter  becomes  effectually  plugged,  either  it  may  be  forced  out 
by  the  efforts  of  the  bladder  to  empty  itself  or  the  bladder  may  fill  up 
and  the  patient  present  all  the  signs  and  symptoms  of  distention. 


526     OPERATIONS   ON   PENIS,    SCROTUM,    URETHRA,    AND    PROSTATE 

When,  in  spite  of  the  retaining  apparatus,  the  catheter  is  forced  out, 
it  must,  of  course,  be  replaced  at  once.  A  soft  catheter  cannot  usually 
be  readily  passed  through  a  urethra  which  has  recently  been  operated. 
The  surest  and  easiest  way  to  get  a  soft  catheter  back,  with  the  least 
number  of  attempts  and  the  least  discomfort  to  the  patient,  is  to  make 
the  catheter  rigid  in  the  usual  curve  by  insertion  into  it  of  a  small  sound 
or  probe  to  serve  as  a  stilet.  A  catheter  thus  stiffened  is  to  be  thoroughly 
lubricated  and  inserted  like  a  sound,  remembering  always  that  the 
roof  of  the  urethra  is  supposed  to  be  uninjured  and  is  the  part,  therefore, 
to  follow  as  a  guide. 

If  the  catheter  be  plugged,  but  remain  in  position,  warm  boric-acid 
solution  should  be  forced  through  it  from  a  fountain  syringe  or,  better, 
in  short  sharp  spurts  from  a  hard-rubber  hand  syringe  until  the  clot  is 
dislodged  and  the  drainage  is  well  reestablished.  Sometimes  suction 
will  work  where  pressure  will  not.  Blowing,  on  the  other  hand,  is  not 
to  be  encouraged.  The  author  once  saw  a  case  in  consultation,  after 
external  urethrotomy,  which  presented  the  curious  symptom-complex 
t)f  marked  distention,  no  passage  of  urine,  bulging  and  resonant  bladder. 
The  case  was  cleared  up  by  the  explanation  of  the  surgeon  that  he  was 
accustomed  to  blow  into  the  catheter  to  dislodge  clots.  Rem.oval,  cleaning, 
and  reintroduction  of  the  catheter  saved  the  day.  Where  there  is  much 
bleeding  it  is  always  wise  in  prostate  as  well  as  stricture  cases  to  have 
the  catheter  irrigated  every  half-hour  for  the  first  three  hours  after 
operation  to  forestall  any  such  difficulty. 

Hemorrhage  at  any  time  during  the  first  three  days  after  operation 
may  take  place  from  a  considerable  vessel  in  the  bulb,  or  may  persist 
from  the  very  time  of  operation  where  the  urethra  and  its  surrounding 
tissues  are  congested  from  prolonged  inflammation.  If  the  hemorrhage 
is  from  the  urethra  itself,  as  in  the  case  of  internal  urethrotomy  (see 
p.  518),  it  is  best  controlled  by  the  insertion  of  a  catheter  of  maximum 
size.  Such  a  catheter  gives  uniform  pressure  to  the  whole  urethra  and 
should  stop  the  bleeding.  If  this  is  insufficient,  the  perineal  wound  may  be 
tightly  packed  with  iodoform  gauze,  which  may,  in  addition,  if  one 
chooses,  be  soaked  with  adrenalin  solution  (i:  1000).  If  the  bleeding 
is  arterial  and  not  controlled  by  packing,  it  may  be  necessary  to  get  the 
patient  into  the  lithotomy  position  and  explore  the  region  of  the  wound, 
with  or  without  anesthesia,  to  find  and  tie  the  bleeding  vessel. 

Sepsis. — Infection  in  the  region  of  the  wound  should  be  met  as  sepsis 
everywhere — by  the  maintenance  of  perfectly  free  drainage  and  frequent 
dressing.  Occasionally  in  parts  of  the  urethra  distal  to  the  wound 
peri-urethral  abscess  may  arise,  particularly  if  the  draining  catheter 


EXTERNAL   URETHROTOMY  527 

is  left  in  too  long.  This  is  characterized  by  pain  and  fever,  the  appear- 
ance of  induration  along  part  or  all  of  the  penile  urethra,  and,  in  due 
time,  by  the  escape  of  pus  from  the  meatus,  on  squeezing  the  indurated 
part  or,  possibly,  even  by  the  abscess  pointing  through  the  skin.  This 
complication  should  be  preventable  or,  at  the  worst,  should  be  recognized 
at  once,  before  it  assumes  any  considerable  importance.  The  draining 
catheter  should  be  withdrawn,  the  abscess  kept  empty  by  repeated 
milking,  done  at  least,  for  example,  every  two  hours.  The  urethra, 
from  the  meatus  to  perineal  wound,  should  be  irrigated  with  a  small- 
caliber  soft-rubber  catheter,  first  put  in  deeply  and  gradually  withdrawn 
while  irrigating,  in  order  that  the  whole  urethra  shall  be  cleaned.  This 
should  be  done  every  three  or  four  hours. 

Epididymitis  may  follow  this  operation  by  infection  through  the 
ducts  in  the  prostatic  urethra.  This  is  more  likely  to  appear  also  if 
the  draining  catheter  is  left  in  too  long,  and,  like  peri-urethral  abscess, 
seems  to  depend  upon  the  seropurulent  discharge  which  we  described 
above.  The  catheter  should  be  removed,  the  bladder  should  be  washed 
out  twice  a  day,  the  testicle  should  be  efi&ciently  supported  by  a  tin  shelf 
across  the  thighs  or  by  adhesive  plaster,  and  either  an  ice-bag  or  flax- 
seed poultice  applied,  whichever  is  the  more  agreeable,  though  the 
former  is  more  likely  to  abort  a  beginning  process. 

Persistent  Perineal  Fistula. — Urethral  fistula  after  external  ure- 
throtomy may  be  said  normally  to  persist  for  any  period  from  a  few 
days  to  a  few  weeks,  and  its  time  of  closure  must  vary,  as  in  all  wounds,, 
with  the  ability  of  the  patient  to  heal,  dependent  on  his  resistance 
and  general  state  of  health  and  on  the  local  conditions  in  the  perineum. 
If,  after  several  weeks  (it  cannot  be  stated  more  exactly),  the  amount 
of  urine  passed  by  the  meatus  does  not  continuously  increase  over  that 
passed  through  the  fistula,  there  is  probably  a  mechanical  reason.  A 
valve-like  flap  may  exist  in  the  urethra  Just  distal  to  the  wound,  or  there 
may  be  a  urethral  stricture  distq,l  to  the  w^ound,  either  recurrent  or 
not  originally  cut.  In  any  case  the  cause,  apart  from  any  malignant 
disease,  is  probably  mechanical,  and  the  persistence  of  the  fistula  means 
that  the  urine  chooses  to  take  the  easier  channel  of  exit.  The  treatment 
is  by  the  use  of  sounds  through  the  whole  length  of  the  urethra.  If, 
as  is  usual,  a  meatotomy  has  been  done  at  operation,  the  ordinary  steel 
sound  is  used,  beginning  with  the  largest  size  that  can  be  passed,  and 
increasing  as  rapidly  as  possible,  with  daily  passings,  until  No.  30  or 
31  French  is  reached.  If  meatotomy  has  not  been  done,  the  curved 
Kollmann  dilator  must  be  used. 


528     OPERATIONS   ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 

RUPTURED  URETHRA 

Here  perineal  section  will  have  been  performed  and  a  catheter 
passed  the  full  length  of  the  urethra  and  left  in  place  for  drainage. 
The  urethra,  when  possible,  will  have  been  partly  or  even  entirely 
sewed  up  at  the  torn  place  over  the  catheter.  Some  cases  may  heal 
by  first  intention,  but  more  often  they  behave  as  after  external  urethrot- 
omy. (See  p.  519.)  The  catheter  is  left  in  place  five  to  seven  days, 
unless  there  appears  an  excessive  urethritis  with  toxic  symptoms.  Two 
days  after  the  remoA'al  of  the  catheter  a  steel  sound  or  Kollmann 
dilator  must  be  passed,  and  thereafter  as  in  the  case  of  external 
urethrotomy. 

Complications  and  Sequelae. — Flemorrhage  and  shock  may  be 
considerable;  both  are  amply  met  by  saline  proctoclysis  and  by  abun- 
dance of  pure  drinking-water. 

Extravasation  of  urine  may  occur  unless  the  perineal  wound  is  large 
enough  thoroughly  to  drain  the  region  of  the  trauma.  Not  infre- 
quently there  has  been  a  certain  amount  of  extravasation  of  urine  or 
blood  before  the  case  arrives  in  the  surgeon's  hand.  When  this  occurs, 
every  effort  must  be  made  to  forestall  or  combat  cellulitis. 

PERINEAL  PROSTATECTOMY 

Since  most  patients  on  whom  prostatectomy  is  done  are  somewhat 
advanced  in  years,  it  is  as  well  in  most  of  them  to  begin  salt  solution 
under  the  breasts  at  the  moment  of  operation.     After  the  completion 


Fig.  179. — Watson's  Hard-rubber  Perineal  Drain- 
age-tube. 
Showing  sliding  collar  to  hold  perineal  straps. 


Fig.  180. — Watson's  Perineal  Drainage- 
tube. 
Front  view  of  sliding  collar. 


of  the  operation  the  patient  should  not  leave  the  table  until  all  consider- 
able hemorrhage  has  been  obviously  checked  and  free  passage  of  fluid 
in  and  out  of  the  bladder  through  the  perineal  catheter  (with  two  fenes- 
tra) has  been  clearly  demonstrated.  Two  small  tubes  or  catheters 
fastened  side  by  side  may  be  used  instead  of  one  catheter.     These  serve 


PERINEAL    PROSTATECTOMY  529 

for  inlet  and  outlet  respectively.  One  is  fairly  sure  to  remain  unplugged. 
The  drainage  catheter  is  held  in  by  the  Watson  button  (Fig.  171)  or  by 
the  split  collar-tube,  or  in  some  other  efficient  manner,  and  the  patient 
is  put  to  bed,  the  drainage-tube  being  immediately  connected  with  a 
bottle  hanging  at  the  side  of  the  bed.  The  tubing  should  be  led  out 
under  the  thigh  and  the  knees  supported  by  a  pillow.  In  this  way 
the  patient  is  free  to  turn  in  bed  without  danger  of  pulling  out  the 
catheter. 

Instead  of  a  perineal  catheter,  Watson's  hard-rubber  perineal  drain- 
age-tube may  be  used  (Figs.  179  and  180). 

The  catheter  should  be  removed  at  the  end  of  t\venty-four  to  forty- 
eight  hours,  but  may  need  to  be  replaced.  A  stilet  is  used  to  stiffen 
it  for  the  purpose  of  getting  it  back  if  necessary.  Unless  retention  of  urine 
appears,  the  patient  should  be  set  up  in  bed  the  day  after  operation 
and  should  be  out  of  bed  the  second  day  if  possible.  Cases  in  which 
retention  with  fever  persists  carmot  get  up  so  soon.  A  sound  must  be 
passed  on  the  third  day  and  twice  a  week  thereafter  for  two  to  six  months, 
according  to  the  individual  tendency  to  form  stricture  of  the  urethra. 
(See  also  Cystotomy,  p.  543.) 

Out-of-door  and  general  tonic  treatment  should  be  instituted. 

Complications  and  Seqnelse^. —Hemorrhage. —External  hemor- 
rhage is  unlikely  if  the  wound  has  been  packed.  The  bladder  may 
fill,  however,  and  the  patient  show  signs  of  internal  concealed  hemor- 
rhage, or  the  bleeding  may  not  be  enough  to  give  general  symptoms, 
but  enough,  nevertheless,  to  plug  the  drainage  catheter  with  blood-clot. 
The  drainage,  then,  whether  there  be  signs  of  hemorrhage  or  not,  must 
be  tested  every  hour  or  two  for  the  first  twelve  hours  at  least.  If  it 
stops  as  if  plugged,  fluid  may  be  forced  from  a  relatively  great  height 
in  the  foimtain  syringe  and  so  drive  out  the  clot,  or  a  hand  syringe  may 
force  the  clot  out  and  the  bladder  should  then  be  w^ashed  with  a  solu- 
tion as  hot  as  can  be  borne  until  the  return  is  blood  free.  If  the  hemor- 
rhage then  continues  to  any  considerable  degree,  the  patient  must  be 
put  in  the  lithotomy  position,  the  packing  removed,  the  bleeding  point 
found,  snapped,  and  tied,  and  the  wound  freshly  packed. 

Suppression  of  urine  is  combated  by  forcing  fluids  into  the  body  by 
all  means — namely,  mouth,  skin,  and  rectum;  by  exhibition  of  digitalis; 
by  application  of  poultices  or  hot-water  bags  over  the  kidney  regions; 
by  hot  pack  or  hot-air  bath  if  the  matter  becomes  serious. 

Retention  of  Urine. — In  the  median  perineal  incision  type  of  opera- 
tion, such  as  that  of  Watson  and  others,  the  sphincter  is  either  stretched 
to  temporary  paralysis  or  so  torn  that  what  urine  appears  in  the  bladder 
34 


530     OPERATIONS   ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 


later  usually  drains  without  trouble.  In  the  dissection  operations  of 
the  Young  type,  the  sphincter,  as  a  rule,  is  not  affected,  and  on  re- 
moval of  the  catheter  the  cases  with  long  dilated,  fibrous,  degenerated 
bladder  walls  will  continue  to  fill  up  in  an  atonic  manner,  just  as  they 
did  before  operation.  In  these  cases,  therefore,  constant  drainage  must 
be  maintained,  sometimes  many  weeks,  with  irrigations  one,  two,  or 
three  times  daily  with  hot  boric  acid,  salt  solution,  or  potassium  per- 
manganate, until  a  certain  amount  of  tone  is  recovered.  Any  type  of 
operation  should  be  followed  by  bladder  washings  until  there  is  no 
evidence  of  atonicity  or  cystitis. 

Infection. — The  case  may  die  almost  immedi- 
ately from  surgical  kidney;  extensive  infection  of 
the  wound  may  appear  in  cases  of  chronic  foul 
bladder  poorly  prepared  for  operation;  in  patients 
much  debilitated;  after  operations  involving  much 
mutilation.  Free  drainage  and  careful  and  fre- 
quent dressings  constitute  the  treatment. 

Persistent  Perineal  Fistula, — It  is  to  be  decided 
that  this  condition  exists,  not  necessarily  upon  per- 
sistence for  a  number  of  weeks  or  months,  but  only 
if  there  is  exhibited  no  tendency  for  the  amount  of 
perineal  discharge  to  diminish,  and  at  the  same 
time  if  it  be  certain  that  the  urethra  is  patent. 
Some  effort  to  stimulate  healing,  in  the  way  of  bal- 
sam of  Peru,  nitrate  of  silver.  Friar's  balsam,  etc., 
Sounds  should  maintain  the  urethra  at  No.  30 
French.  After  six  months  a  secondary  operation  to  close  the  fistula 
should  be  done. 

Persistence  of  incontinence,  either  through  a  perineal  fistula  or  through 
the  meatus,  signifies  a  probable  incurable  injury  to  the  sphincter.  For 
this,  however,  the  application  of  static  electricity,  with  one  electrode  on 
the  perineum  and  one  over  the  lumbar  spine,  may  be  tried.  An  ambu- 
latory urinal  (Fig.  181)  should  be  used  when  necessary.  Excoriations 
should  be  prevented  by  applications  to  the  skin. 


Fig.  181. — Male  Urinal. 

Soft-rubber,  suspended  by 

belt,  worn  in  trouser-leg. 


should   be    made. 


SUPRAPUBIC  PROSTATECTOMY 

This  operation,  though  relatively  in  disfavor  in  American  practice 
at  the  present  writing,  seems  to  have  the  advantage  that  it  affords  in- 
spection of  the  prostatic  tumor  and  perhaps,  therefore,  more  deliberate 
treatment  with  regard  to  the  special  formation  that  the  enlargement  pre- 
sents; and  that  a  suprapubic  cystotomy  may  be  done  some  time  previous 


SUPRAPUBIC   PROSTATECTOMY 


531 


to  the  removal  of  the  prostate,  thus  giving  time  for  draining  and  cleaning 
up  a  distended  foul  bladder.  It  has  the  disadvantage  that  adequate 
drainage  is  difl&cult  and  that  ascending  infection  of  the  kidneys  seems 
liable  to  occur. 


Fig.  182.— Suprapubic  Drainage. 
Four  small-caliber  soft-rubber  tubes  fused  together  (Dr.  Horace  Packard). 

The  patient  is  put  to  bed  and  drainage  through  the  urethra  and 
the  suprapubic  wound  is  immediately  established.  An  ingenious  and 
adequate  method  has  been  devised  by  Dr.  Horace  Packard/  of  Boston 
(Fig.  182).   Some  operators  prefer  a  single  tube  with  a  diameter  of  as  much 


Fro.  183. — Suprapubic  Cystotomy. 
Constant  drainage.     Tube  is  pinned  to  the  bed  to  allow  sufficient  slack  for  patient  to  turn  about.     Boltle  is 

hung  to5ide-iron  of  bed. 

as  I  inch.  Without  special  apparatus,  however,  drainage  can  be  efficient 
if  the  patient  receives  intelligent  and  conscientious  attention  day  and 
night  for  the  first  three  or  four  days.  He  should  sit  up  in  bed  the  day  after 
operation  and  in  a  chair  as  soon  as  possible,  returning  to  nearly  normal 

^  N.  E.  Med.  Gaz.,  1907,  xvii,  13. 


532     OPERATIONS    ON   PENIS,    SCROTUM,    URETHRA,    AND   PROSTATE 

conditions  with  as  great  rapidity  as  is  allowed.  Water  is  forced  into  the 
body  by  all  methods  from  the  very  moment  of  operation.  Urinary 
antiseptics  are  given  constantly.  For  other  details  of  after-treatment 
see  Suprapubic  Cystotomy  (p.  543)  and  General  Considerations  on 
Geni to-urinary  Cases  (p.  510). 

Complications  and  Sequelae. — Shock  complicated  with  hemor- 
rhage is  probably  the  commonest  cause  of  death.  Saline  solution, 
adrenalin,  heaters,  all  the  means  already  described  (Chap.  VII,  p.  82), 
are  to  be  at  hand. 

Hemorrhage. — The  patient  should  not  leave  the  table  until  all 
notable  hemorrhage  has  been  checked.  If  a  considerable  bleeding 
starts  up  in  bed,  the  prostatic  cavity  must  be  packed  through  the  supra- 
pubic wound.  The  packing  should  be  of  iodoform  gauze  or  plain  gauze 
saturated  with  adrenalin  if  necessary.  The  packing  should  be  removed 
in  most  cases  at  the  end  of  twelve  hours. 

Sepsis. — Ascending  infection  may  cause  a  double  pyelitis,  which  may 
be  rapidly  fatal.  Mere  absorption  of  septic  products  from  the  prostatic 
wound  cavity  in  cases  inefficiently  drained  is  enough  to  cause  fatal  issue. 
In  the  latter  case  treatment  is  obvious.  In  pyelitis  large  quantities  of 
water,  urinary  antiseptics,  poultices  or  heaters  over  the  kidney  regions, 
and  general  supportive  treatment  should  give  results.  Suppression  of 
urine  is  always  to  be  feared.  Prophylaxis  by  means  of  previous  water 
saturation  should  be  efficient  against  it,  but  if  diminished  secretion 
just  after  operation  is  apparent,  besides  salt  solution  under  the  skin, 
the  patient  should  be  given  poultices  over  the  kidney  regions  and  diu- 
retics by  mouth.  Sweating,  using  a  hot-air  bath  when  indicated,  should 
be  induced. 

PROSTATOTOMY  FOR  PROSTATIC  ABSCESS 

Inasmuch  as  prostatic  abscess  can  almost  always  be  opened  without 
entering  the  urethra,  it  is  to  be  treated  as  any  abscess:  iodoform  gauze 
tampon  for  first  dressing,  rubber  tube  subsequently  if  the  skin-wound 
tends  to  close  too  rapidly. 

Constant  urethral  drainage  may  be  necessary  in  some  cases  because 
of  spasmodic  or  inflammatory  retention.  Frequent  hot  sitz-baths  aid 
drainage  and  give  great  relief.  The  coincident  gonorrhea  must  be 
treated. 


CHAPTER  XL VIII 

OPERATIONS  ON  THE  KIDNEY,  URETER,  AND  BLADDER 

NEPHROTOMY 

The  kidney  may  be  subjected  to  a  small  incision,  as  for  abscess,  or 
it  may  be  split  open  its  entire  length  in  order  to  get  out  a  large  stone  or 
a  number  of  stones  in  the  pelvis  or  the  calices.  The  loss  of  blood 
after  either  procedure  is  usually  considerable.  If  necessary,  the  ap- 
propriate constitutional  treatment  for  hemorrhage  should  be  instituted. 
(See  Chap.  VI.)  The  shock  following  this  operation  is,  most  likely,  due 
in  great  measure  to  the  hemorrhage.  If  the  kidney  was  found  to  con- 
tain stones  and  no  appreciable  amount  of  pus,  the  wound  in  the  kidney 
is  to  be  closed  by  interrupted  mattress  sutures  of  No.  i  or  2  chromic 
catgut.  This  should  immediately  control  hemorrhage  and  should  give 
a  fair  chance  of  primary  healing  of  the  kidney  wound.  A  cigarette 
or  spiral  drainage  leads  down  to  the  kidney. 

If  the  pus  in  the  kidney  is  enough  in  amount  to  make  it  merely  a 
pus-cavity,  or  if  the  hydronephrosis  is  such  that  only  a  shell  remains, 
and  if  also  it  has  been  determined  before  the  operation  that  the  patient 
has  another  kidney  (by  cutting  down  on  it  or  by  catheterizing  the  ureters), 
a  nephrectomy  will  be  done  either  primarily  or  after  splitting  the  kidney. 
(See  p.  539.) 

If,  however,  for  any  reason  the  kidney  itself  is  to  be  drained,  a  spiral 
drain  with  2  in.  of  gauze  protruding  from  one  end  may  be  packed  into 
the  purulent  or  bleeding  cavity.  A  voluminous  dressing  is  applied  and 
the  patient  lies  on  his  back  with  an  additional  small  hard  pad  under 
the  lumbar  region  to  help  prevent  backache.  Saline  adrenalin  solu- 
tion-— 0.6  and  1 :  50,000,  made  by  adding  common  salt  (i  dram)  and 
adrenalin  solution,  i :  1000  (2I  drams)  to  i  pint  of  sterile  water — should 
be  started  under  the  breasts  as  soon  as  the  patient  is  on  his  back,  and 
should  be  given  to  the  limit  of  capacity  of  both  breasts.  Salt  solution 
should  also  be  started  by  the -slow  method  per  rectum  and  kept  going 
twenty-four  hours.  Tincture  of  digitalis  or  strophanthus  may  be  added 
to  the  enema  if  it  seems  best,  and  i>lTychnin  given  subcutaneously 
(•^Iq  gr.)  every  one  to  six  hours  if  indicated.  The  pads  must  be 
changed  as  often  as  they  are  wet.     The  patient  must  be  kept  warm  to 

533 


534  OPERATIONS    ON  THE   KIDNEY,    URETER,    AND   BLADDER 

the  extent  of  mild  perspiration,  and  must  be  encouraged  in  every  way 
to  drink. 

Occasionally  bleedmg  occurs  on  removing  the  packing  which  has 
been  placed  in  the  kidney,  because  the  blood-vessels  in  this  organ  have 
especially  thin  walls.  On  this  account  it  is  well  to  postpone  withdrawing 
the  tampon  until  it  has  been  loosened  by  the  suppurative  process,  and 
even  then  it  should  be  removed  a  little  at  each  dressing  until  it  has  all 
been  loosened.  In  the  mean  time  the  urine  drains  round  the  gauze, 
through  the  wound,  and  the  mucous  membrane  lining  the  ureter  has 
an  opportunity  to  become  normal,  because  the  flow  of  purulent  urine 
through  it  has  ceased.  The  urine  usually  becomes  clear  in  a  few  days 
because  the  drainage  is  so  free  that  there  is  no  accumulation.  The  pelvis 
of  the  kidney  contracts  for  the  same  reason. 

For  nourishment  during  the  first  week  milk  should  be  the  main  re- 
source. Begin  by  adding  an  equal  quantity  of  boiling  water,  together 
with  a  little  lime-water.  After  that  start  soft  solids  and  begin  a  rapid 
resumption  of  house  diet.  The  amount  of  meat  and  eggs  in  the  diet  will 
depend  somewhat  upon  the  chemical  composition  of  the  stones  removed 
and  upon  the  reaction  of  the  urine  during  convalescence.  In  a  urine 
which  tends  to  be  strongly  acid  meat  once  a  day  is  probably  best.  If 
the  urine  is  alkaline,  more  may  be  given.  If  the  urine  continues  to  be 
alkaline,  sodium  benzoate  (5  gr.),  dissolved  in  a  glassful  of  water,  should 
be  given  three  or  four  times  a  day.  Whether  the  urine  contains  pus 
or  not  during  the  first  two  or  three  weeks,  hexamethylamin  should  be 
given,  5  to  7^  gr.,  dissolved  in  much  water,  three  or  four  times  a  day, 
with  a  view  to  rendering  the  urine  sterile  and  bland. 

The  amount  of  urine,  day  and  night,  separately,  should  be  carefully 
noted  from  the  first,  together  with  any  gross- appearance  of  blood  therein. 
The  blood  should  diminish  and  not  be  apparent  to  the  naked  eye  after 
the  third  day  in  most  cases. 

Double  nephrotomy  offers  some  curious  problems  in  after-treat- 
ment, as  a  personal  communication  from  Dr.  F.  S.  Watson  will  show. 


**  The  features  of  the  after-treatment  of  that  case  of  double  nephrotomy  were: 

"  (i)  The  manner  of  arranging  the  drainage  (Figs.  184,  185,  186). 

"  (2)  The  fact  of  the  infection,  and  acute  abscess  of  the  second  kidney,  some  nine  j-ears 
after  the  first  one  had  been  operated  upon  also  for  acute  abscess. 

"  (3)  The  fact  that  the  patient  has  been,  except  for  some  few  weeks  of  which  I  will 
speak  in  a  moment,  comfortable,  free  from  disagreeable  odor,,  dry,  and  without  disa- 
bility, he  having  pursued  an  active,  hard-working  life  during  the  whole  time  since  the  first 
operation,  which  was  in  1894,  with  the  above  noted  exception. 

"  (4)  The  fact  that  the  first  kidney  operated  upon,  which  was  so  greatly  injured  as  to 
bave  made  it  seem  wise  to  have  removed  it  at  the  outset,  had  the  patient's  condition  at  the 


NEPHROTOMY  535 

time  allowed  it  to  be  done,  has  ever  since  the  original  operation  continued  to  supply  urine 
having  a  specific  gravity  of  from  loii  to  1017,  and  urea  from  1.30  to  1.50,  taking  2  as  the 
normal  quantity  (the  second  kidney  was  much  less  seriously  and  less  extensively  damaged, 
although  it  had  a  large  abscess  in  it),  has  secreted  a  urine  of  nearly  normal  quantities  of 
the  solid  constituents,  since  it  was  operated  upon.  The  drainage  through  the  loins  has 
been  uninterrupted  from  the  time  of  its  being  instituted  in  both  kidneys — fifteen  years 
in  all. 

"  (5)  The  fact  that  the  patient  went  on  in  perfectly  good  health  for  twelve  years  with- 
out any  evidence  of  calculus-formation  in  either  kidney. 

"  (6)  That  he  then  began  to  have  calculi  from  both  kidneys,  which  continued  for  several 
months,  when  I  operated  on  the  right  and  later  on  the  left  kidney,  removing  a  lot  of  gravel 
and  putty-like  phosphatic  concretions  and  calculous  material  in  small  masses  from  one 
kidney  and  a  large  single  phosphatic  calculus  from  the  other. 

"  (7)  The  fact  that  he  has  had  no  symptoms  of  renal  calculus  since  these  operations, 
two  years  ago,  and  continues  to  be  in  excellent  condition  and  hard  at  work. 

"  (8)  That  the  urine  has  since  then  become  much  clearer  than  at  any  pre^dous  time  and 
is  free  from  blood. 

"  These  are  the  most  interesting  features  of  the  case  subsequent  to  operation. 

"  The  kidneys  have  been  washed  out  night  and  morning  ever  since  the  operation  with 
1 :  4000  or  6000  solution  of  potassium  permanganate,  or  sterile  saline  solution,  or  boric 
acid,  4  per  cent,  solution,  through  the  "Watson  drainage-tubes.  The  tubes  have  been 
changed  for  clean  ones  each  time  this  has  been  done.  The  fistulae  have  never  been  allowed 
to  contract,  and  the  drainage-tubes  have  always  been  kept  of  large  size,  their  calibers  about 
§  in.     The  best  possible  drainage  has  thus  been  maintained. 

"  Finally  hemorrhage  took  place  from  the  kidney  operated  on  first,  twelve  years  after 
the  operation.  Nevertheless,  daily  irrigations  went  on  as  usual.  Two  weeks  later  he 
came  to  my  office,  and  upon  having  the  tube  from  the  kidney  replaced  after  it  had  been 
withdrawn  to  cleanse  it,  and  without  any  trouble  having  occurred  in  the  getting  it  back 
again,  a  sharp  hemorrhage  suddenly  occurred  from  that  kidney,  I  succeeded  in  partially 
controlling  it  and  got  him  to  the  hospital,  where  I  laid  open  the  whole  of  the  tract  of  that 
fistula,  found  the  hemorrhage  to  be  proceeding  from  one  point  especially  of  the  renal  sub- 
stance close  to  the  inner  orifice  of  the  fistula,  and  after  extracting  a  calculus  from  the 
kidney  by  forceps  through  the  now  much  enlarged  canal  of  the  fistula,  I  succeeded  in 
wholly  arresting  the  bleeding  by  tamponing  the  wound  and  bleeding  surface  of  the  kidney, 
after  which  we  had  no  further  trouble  of  any  kind." 

Complications  and  Sequelae. — Secondary  hemorrhage  may  take 
place  at  any  time  for  from  a  few  hours  to  weeks,  months,  or  even  years 
after  operation  if  fistula  persists.  This  may  be  due  to  inefficient  hemo- 
stasis  at  the  time  of  operation;  it  may  be  due  to  ulceration  of  a  remaining 
stone  into  a  renal  vessel;  it  may  be  due  to  the  presence  of  an  unsuspected 
new-growth  underlying  the  stones,  or  may  be  apparently  a  general  venous 
ooze  from  the  whole  cut  surface.  Such  bleeding  must  be  met  for  the 
time  being  by  packing  the  wound  with  gauze  soaked  with  adrenalin,  or 
at  any  time  by  secondary .  operation,  even  by  nephrectomy,  if  packing 
does  not  control  it. 

Sepsis. — This  may  be  superficial  or  deep,  and  may  or  may  not  cause 
general  symptoms.  If  the  kidney  has  been  torn  and  the  urine  was  foul, 
or  if  repeated  packing  has  been  necessary  to  stop  bleeding,  deep  infec- 


536  OPERATIONS    ON    THE    KIDNEY,    URETER,    AND    BLADDER 

tion  will  probably  appear.  For  this  condition  drainage  must  be  free 
and  efficient. 

Suppression  or  uremia  may  take  place  at  once,  or  at  any  time  up  to 
two  weeks.  It  is  seen  more  often  in  those  beyond  middle  life  and  in 
those  with  stiff  arteries  and  high-tension  pulse,  or  in  those  in  whom  the 
other  kidney  is  suffering  with  stone  or  other  disease.  Preventive  treat- 
ment (p.  510)  is,  of  course,  the  most  important.  Every  means  must  be 
taken  to  produce  sweating  and  diuresis. 

Persistent  urinary  fistula  after  nephrotomy  presents  a  difficult  prob- 
lem. Until  the  ureter  has  become  normal,  and  especially  in  cases  in 
which  the  disease  has  existed  a  long  time,  the  wound  in  the  kidney  will 
not  heal,  and  a  fistula  may  persist,  which  is  not  only  disagreeable,  because 
of  the  odor  and  sensations  of  dressings  constantly  wet,  but  also  because 
it  results  in  distressing  excoriations  of  the  skin  on  account  of  the  irrita- 
tion of  the  urine.  The  problem  of  collecting  the  urine  from  such  a  fistula 
so  as  to  allow  the  patient  to  lead  an  ambulatory  life  is  well  met  by  Dr. 
F.  S.  Watson's  ingenious  apparatus.  The  apparatus  consists  of  the 
following  parts: 

(i)  A  cup-shaped  hard-rubber  shield  perforated  by  two  holes,  one  in  the 
center  of  the  shield  and  having  the  size  of  No.  28  of  theFrench  scale  of  measure- 
ment for  urethral  instruments;  the  other,  which  is  somewhat  smaller  than  the 
first,  is  placed  just  within  and  at  the  lowest  point  of  the  cup  of  the  shield.  A 
short  hard-rubber  tube  is  fitted  into  the  last-named  hole,  and  onto  the  farther 
end  of  this  tube  is  attached  another  of  soft  rubber  which  passes  to  the  smaller 
of  the  two  upright  tubes  of  metal  that  are  upon  the  upper  surface  of  the  re- 
ceptacle (Fig.  185). 

The  leakage,  which  is  so  distressing  a  feature  to  the  patient,  and,  because 
of  the  uriniferous  odor,  makes  the  condition  so  unpleasant  to  others,  takes 
place  around  the  outer  sides  of  the  tube  which  drains  the  kidney.  It  is  this 
leakage  which  must  be  pro\dded  for  by  the  apparatus,  and  it  is  done  in  a  very 
simple  manner  by  this  contrivance,  thus:  As  fast  as  the  urine  escapes  upon 
the  surface  of  the  body  it  is  necessarily  caught  vithin  the  cup  of  the  shield 
and  is  ^vithdraw^l  from  it  by  the  small  tube  which  drains  the  latter  as  fast  as 
the  urine  collects  in  it,  and  conveys  it  to  the  receptacle.  The  shield  is  provided 
with  a  soft-rubber  rim,  which  fits  into  the  raised  edge  of  the  rubber  cup,  and 
the  shield  is  kept  firmly  pressed  against  the  surface  of  the  body  by  an  elastic 
belt  which  is  attached  to  each  of  its  wings  and  which  buckles  in  front  (Fig. 
184). 

(2)  A  receptacle  made  of  German  silver  which  has  a  capacity  of  9  ounces. 

(3)  A  second  belt,  which  is  attached  to  the  receptacle  in  the  manner  shown 
in  Fig.  184,  and  which  also  passes  around  the  body  and  buckles  in  front. 

(4)  Upon  the  lower  part  of  the  can  is  a  metal  cap,  which  can  be  detached 


NEPHROTOMY 


537 


from  it.  From  the  middle  of  this  cap  projects  a  short  metal  tube,  over  the  end 
of  which  a  soft-rubber  tube  is  slipped;  the  further  end  of  this  tube  is  furnished 
with  a  hard-rubber  cap,  by  unscrewing  which  a  hole  is  opened  in  its  stem  and 
allows  the  contents  of  the  can  to  escape  through  it.  Except  at  the  time  at 
which  the  can  is  being  thus  emptied,  the  end  of  the  tube  is  worn  beneath  one 
of  the  elastic  belts,  which  retains  it  at  whatever  point  is  most  convenient  to 
the  wearer  (Fig.  i86). 

(5)  The  only  other  feature  of  the  apparatus  which  requires  description  is 
the  arrangement  by  which  the  tubes  connecting  the  shield  with  the  receptacle 
are  attached  to  the  latter.     This  is  done  by  passing  the  lower  ends  of  the  soft- 

r 


Fig.  184. — Watson's  Apparatus  for  Permanent  Drainage  of  the  Kidney  Through  the  Loin  (Watson 

AND  Cunningham). 

rubber  tubes  into  the  two  metal  nozzles — or,  if  preferred,  slipping  them  over 
them — which  are  placed  upon  the  upper  part  of  the  receptacle.  The  man- 
ner in  which  the  connection  is  made,  as  well  as  the  relative  positions  of  the 
shield  and  receptacle  and  othejr  details  of  the  apparatus,  are  shown  in  Figs. 
184  and  185. 

Fig.  T,86  shows  the  apparatus  as  it  appears  when  properly  placed  on  the 
patient's  back. 

The  further  points  to  be  noted  in  connection  with  it  are  as  follows: 
The  hole  in  the  shield  through  which  the  tube  which  drains  the  kidney 
passes  must  be  a  little  smaller  than  the  tube,  in  order  that  the  latter  shall  bind 


538 


OPERATIONS    ON   THE   KIDNEY,    URETER,    AND    BLADDER 


it  in  and  thus  be  prevented  from  slipping  to  and  fro.     If  in  any  case  the  tube 
should  be  too  small  to  do  this,  its  size  can  be  increased  by  slipping  over  it  a 


Fig.  185. — Watson's  Apparatus  (Watson  and  Cunningham). 
Cup-shaped  hard-rubber  shield  of  Watson's  apparatus  for  permanent  renal  drainage  through  the  loin. 

short  bit  of  another  and  larger  tube  at  the  point  at  which  it  passes  through 
the  shield.  ■?»«?«««>.  -  .        -   ^    ~  , , — 


Fig.  186. — Watson's  Apparatus  for  Permanent  Drainage  of  the  Kidney  as  Applied  (Watson  and 

Cunningham). 


The  receptacle  can  be  worn  inside  the  trousers,  and  is  so  small  and  flat 
that  it  attracts  no  attention  and  causes  no  discomfort. 


NEPHRECTOMY  539 

Instead  of  a  receptacle  of  this  form  the  ordinary  portable  rubber  urinal, 
which  is  attached  to  the  leg,  may  be  worn  if  preferred,  the  connecting  tubes 
being  united  into  one,  near  the  shield,  and  lengthened,  as  may  be  required. 
The  objection  to  this  arrangement  is  the  difficulty  of  keeping  the  rubber  bag 
clean  and  odorless. 

At  night  the  metal  receptacle  is  detached,  the  tubes  of  the  shield  are 
lengthened  by  attaching  others  to  them,  and  these  are  carried  to  a  bottle  or 
other  receiving  vessel  placed  beside  the  bed.  The  patient  should  assume  a 
semirecumbent  position  at  night  in  order  to  secure  the  best  drainage  of  the  cup 
of  the  shield. 

The  connections  of  the  belts  with  the  shield  and  can  respectively  should  be 
so  arranged  as  to  be  detachable,  in  order  that  the  other  parts  of  the  apparatus 
can  be  boiled,  which  should  be  done  once  daily.  The  tube  draining  the 
kidney  should  be  changed  for  a  fresh  one  each  day,  the  one  not  in  use  being 
kept  in  an  antiseptic  fluid. 

When  the  tube  which  drains  the  kidney  has  been  properly  adjusted  in  the 
organ,  a  mark  should  be  made  upon  it  at  the  point  at  which  it  emerges  from  the 
outer  side  of  the  shield,  in  order  to  avoid  the  necessity  of  having  to  readjust 
the  tube  each  time  that  it  is  changed. 

The  tube's  inner  end  should  rest  within  the  renal  pelvis  in  most  cases,  and 
should  be  so  placed  as  to  cause  no  pain  to  the  patient. 

NEPHRECTOMY 

The  dressing  should  not  be  so  voluminous  that  it  makes  a  mass 
uncomfortable  to  lie  on.  Temporary  drainage  is  in  the  renal  space. 
In  bed  the  patient  is  surrounded  by  heaters,  and  symptoms  of  shock  and 
hemorrhage  attended  to  as  they  appear.  Uncomplicated,  the  sutures 
should  be  out  on  the  tenth  day,  the  patient  up  when  the  remaining 
kidney  seems  to  have  assumed  its  doubled  function. 

If  the  nephrectomy  has  been  for  tuberculosis  of  the  kidney,  it  is  to 
be  supposed  that  the  ureter  was  followed  down  and  removed.  In  the 
wound,  therefore,  if  there  is  any  question  of  tuberculosis  remaining,  it 
should' be  treated  later  by  repeated  applications  of  tincture  of  iodin, 
as  in  tuberculous  wounds  elsewhere. 

Abdominal  nephrectomy,  a  very  rare  operation,  calls  for  no  special 
consideration  apart  from  nephrectomy  in  general. 

Complications  and  Sequelae. — Suppression  of  Urine.- — After- 
care of  nephrectomy,  as  in  nephrotomy,  should  be  at  first  directed  to- 
ward encouraging  the  other  kidney  to  rise  to  its  increased  labor.  It 
has  been  contended  by  some  that  too  high  an  arterial  pressure  might 
be  induced  by  forcing  the  ingestion  of  fluids,  but  it  seems  to  me  doubtful 
if  suppressive  congestion  of  the  other  kidney  is  ever  due  alone  to  pressure 


540 


OPERATIONS  ON  THE  KIDNEY,  URETER,  AND  BLADDER 


from  too  great  a  volume  of  blood  in  the  systemic  circulation.  It  seems 
more  probable  that  uremic  suppression  is  due,  on  the  contrary,  to  the 
concentration  of  blood  containing  too  much  matter  to  be  excreted. 
The  same  consideration  may  be  applied  to  meet  the  objection  that 
one  should  seek  to  avoid  the  raising  of  blood-pressure  until  thrombosis 
is  well  established  in  the  renal  pedicle  after  nephrectomy. 

In  the  matter  of  postoperative  suppression  there  is  one  prophylactic 
possibility  of  which  too  litde  is  ordinarily  said.  To  quote  F.  Tilden 
Brown *:  "A  word  about  the  prevailing  method  of  posturing  patients 
for  nephrectomy.     Of  course,  an  extension  of  the  iliocostal  space  greatly 


Diannosis  fJepTirectomy. 

OISE^SF. 

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Fig.  187. — Nephrectomy  for  Suppurating  Kidney,  Drained. 

facilitates  operation.  This  is  ordinarily  secured  by  bags  of  sand  or  air 
underlying  the  opposite  anterolateral  region  of  the  abdomen.  When, 
by  such  an  arrangement,  the  .spine  is  sufficiently  flexed  to  extend  the 
operative  field,  the  pelvis  is  nearly  lifted  from  the  table,  and  the  pyramidal 
support  thus  bears  a  considerable  part  of  the  total  weight  of  the  body. 
This  pressure  impinges  upon  a  yielding  surface  immediately  about  the 

^  Non-obstructive,  Postoperative  Anuria,  Ann.  Surg.,  1901,  .xxxiii,  225  et  seq. 


NEPHRORRHAPHY  54I 

sound  kidney,  and  that  the  organ  may  be  heavily  compressed  against 
the  spine,  with  deleterious  consequences,  appears  to  us  quite  possible. 
Experiments  showed  that  30  per  cent,  of  the  body  weight  was  in  this 
way  superimposed  on  this  region  alone." 

This  evil  is  avoided  by  the  use  of  an  operating-table  with  the  double- 
inclined  plane  arrangement  (such  as  the  Cunningham  table) ,  but  it  would 
seem  as  if  there  should  be  an  actual  gap  between  the  planes  to  underlie 
that  part  of  the  trunk  which  ordinarily  sustains  all  the  lifting  strain  in 
the  varieties  of  "nephrectomy"  tables.  As  Dr.  Brown  says:  "We  feel 
that  every  consideration  should  be  accorded  to  the  single  healthy  gland 
(kidney)  during  the  removal  of  its  mate." 

Nitroglycerin  and  adrenalin,  which  cause  a  rapid  rise  in  arterial  ten- 
sion, should  be  avoided  if  possible.  The  surgeon  should  rather  trust  to 
strychnin  with  digitalis  or  strophanthus  to  overcome  the  shock  of  oper- 
ation. The  observer  may  be  easily  led  to  mistake  a  condition  of  delayed 
surgical  shock  for  auto-intoxication  due  to  renal  suppression.  The 
former  is  probably  the  more  likely,  and  should  be  ruled  out  before 
anuria  is  diagnosticated. 

Hemorrhage. — At  the  time  of  operation  the  ligatures  must  be  placed 
with  all  the  care  possible,  using  the  so-called  surgeon's  knot,  as  small  a 
mass  being  included  in  each  tie  as  is  feasible.  The  wound  should  be 
well  retracted  and  well  lighted,  and  every  oozing  point  which  appears 
after  fairly  vigorous  sponging  should  be  deliberately  tied.  If  bleeding 
still  persists,  or  cannot  be  reached  by  ligature,  the  hemostatic  forceps  or 
clamp  should  be  left  in  situ  for  two  days.  If  this  is  done,  the  greatest 
care  must  be  taken  to  so  build  the  dressing  round  the  handle  of  the 
forceps  and  to  so  place  the  patient  that  the  weight  of  the  body  in  the 
recumbent  posture  shall  not  bear  on  the  forceps.  In  some  cases  the 
dressing  pad  stains  through  with  bright  blood  repeatedly  to  an  extent 
which  is  disturbing.  If  this  occurs,  particularly  with  rising  pulse,  and 
it  is  known  that  every  reasonable  effort  was  made  to  control  bleeding  by 
direct  ligation  at  the  time  of  operation,  the  patient  should  be  turned  over 
on  the  well  side,  the  wound  opened  and  tighdy  packed  with  iodoform  or 
some  other  chemically  treated  gauze.  In  packing  a  capacious  cavity 
of  this  sort  one  should  leave  the  end  of  each  strip  which  has  been  intro- 
duced protruding  from  the  wound,  in  order  that  later,  when  the  pack- 
ing is  removed,  nothing  may  be  left. 

NEPHRORRHAPHY 

This  operation  is  rarely  necessary.  Whatever  the  type  of  operation 
used,  the  patient  should  be  on  the  back  about  twenty-one  days  to  allow 


542 


OPEEATIONS  ON  THE  KIDNEY,  URETER,  AND  BLADDER 


thorough  organization  of  the  adhesions  about  the  kidney  in  its  new 
place.  After  this  the  patient  may  acquire  strength  as  rapidly  as  pos- 
sible, avoiding,  however,  great  muscular  strain,  such  as  requires  the 
fixing  of  the  diaphragm  and  reaching  upward  or  backward.  Other 
than  this  there  are  practically  no  special  directions  for  convalescence. 

Complications  and  Sequelae. — Kink  in  the  Ureter. — It  is  pos- 
sible that  by  the  operation  the  kidney  has  been  fastened  in  such  a  posi- 


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Uneventful  recovery. 


tion  as  to  kink  the  ureter  or  to  interfere  with  the  blood-supply.  This  is 
called  strangulation  or  acute  dislocation  of  the  kidney,  and  an  immediate 
secondary  operation  may  be  necessary. 

The  newly  fixed  kidney  may  tear  away.  Even  so,  if  the  patient  be 
kept  on  his  back,  there  should  be  enough  raw  surface  in  the  region  of  the 
wound  to  enable  the  kidney  to  adhere.  Certainly  no  second  operation 
should  be  attempted  for  many  months  at  least. 


SUPRAPUBIC    CYSTOTOMY 


543 


OPERATIONS  UPON  THE  URETER 
After  operations  upon  the  ureter,  whether  the  operation  has  been 
for  ureteral  obstruction  or  for  accidental  or  operative  injury  to  the 
ureter,  the  wound  must  be  drained  down  to  the  site  of  ureteral  operation, 
but  in  such  a  way  that  there  shall  be  no  obstruction  due  to  the  drain.  If 
urine  escapes  to  a  notable  degree  from  the  wound,  means  should  be  taken 
to  protect  the  skin  (p.  514)  or  to  collect  the  urine,  as  in  a  persistent 
nephrotomy  fistula  (p.  536). 

SUPRAPUBIC  CYSTOTOMY 
In  these  cases  it  is  assumed  that  the  bladder  is  closed  by  interrupted 
catgut  sutures,  but  the  wound  down  to  the  bladder  is  left  open.  This 
procedure  may  be  followed  unless  one  of  the  following  conditions  is 
present:  (i)  Cystitis,  especially  with  foul-smelling  urine;  (2)  when  the 
stone  was  partially  embedded  in  the  bladder-wall  or  for  any  other  reason 
the  bladder  was  torn  or  bruised,  as  in  the  separation  of  a  tumor;  (3) 
hemorrhage,  either  present  or  reasonably  to  be  expected.  If  the  bladder 
is  closed  in  this  condition,  it  will  fill  with  clot,  cause  violent  tenesmus, 
and  finally  tear  itself  open  through  the  line  of  sutures. 

"The  drainage  of  the  bladder  (after  suprapubic  cystotomy)  by  catheter 
in  the  urethra  and  siphonage  is  so  difficult,  the  patients  being  so  unsatisfact- 
ory for  the  first  week  or  so,  owing  to  the  constant  soakage  in  spite  of  volumin- 
ous dressings,  that  wherever  it  is  possible  the  bladder  opening  should  be  closed 
by  sutures.  This  is  especially  the  case  in  elderly  flabby  patients  with  dam- 
aged kidneys  and  unsatisfactory  vital  power  and  will.  Such  tend  to  become 
apathetic,  to  lie  helplessly  on  their  backs,  down  in  the  bed,  thus  easily  get 
stasis  in  their  lung  bases  and  bronchopneumonia,  together  with  a  low  septic 
condition  of  the  wound.  The  nursing  in  such  cases  is  greatly  helped  by  sutur- 
ing of  the  wound,  thus  keeping  the  patients  dry.  One  of  the  first  to  adopt  this 
plan  successfully  was  Dr.  L.  S.  Pilcher,  of  New  York:  a  catheter  was  used  until 
the  ninth  day;  the  patient,  an  adult,  went  out  on  the  fourth,  and  on  the  four- 
teenth day  was  shown  to  the  New  York  Medical  Society,  primary  union  ha\dng 
taken  place  throughout  the  whole  extent  of  the  wound,  without  unpleasant 
symptoms  of  any  kind.  Mr.  Anderson  (Lancet,  1890,  i,  898)  sutured  the 
bladder  in  a  boy  aged  ten.  Acute  pneumonia  complicated  the  after-treatment, 
and  on  the  night  of  the  fourth  day  prolonged  coughing  tore  open  the  wound. 
The  case  did  well.  During  the  first  few  days,  if  the  urethral  catheter  becomes 
plugged,  some  urine,  possibly  septic,  may  be  forced  out  between  the  sutures 
before  the  bladder  wound  is  finally  closed.  If  this  extravasation  takes  place 
deep  down  in  a  wound  like  this,  where  the  superficial  parts  have  been  closed, 
there  is  the  gravest  peril  of  a  fatal  issue  from  septic  purulent  infiltration  of 
the  connective  tissue  of  the  cavum  Retzii,  pelvis,  and  abdominal  wall." 

^  Jacobson,  1902,  ii,  404. 


544  OPERATIONS    ON   THE   KIDNEY,    URETER,    AND   BLADDER 

Complications  and  Sequelae. — Shock  may  appear  immediately 
after  operation.  This  is  partly  because  patients  are  frequently  old; 
because  persistent  hemorrhage  has  been  usually  going  on  for  a  long 
time  before,  and  because  during  operation  there  may  have  been  con- 
siderable hemorrhage. 

Hemorrhage. — Bleeding  may  continue  unchecked  from  the  time  of 
operation  or  may  start  up  secondarily  two  or  three  days  after  operation. 
Where  the  growth  was  in  the  lower  segment  of  the  bladder,  near  the 
exit,  if  bleeding  is  not  stopped  by  simple  packing,  a  small  bougie  may 
be  passed  by  urethra  into  bladder,  and  a  tampon  may  be  made  as 
follows:^  A  small  shirt-button  is  placed  in  the  center  of  15  or  20 
layers  of  gauze,  8  or  10  in,  square.  A  long  loop  of  silk  is  passed 
through  the  gauze,  through  the  button,  and  back  through  the  gauze,  and 
the  silk  loop  is  then  pulled  by  means  of  the  bougie  through  the  supra- 
pubic wound  and  out  through  the  urethra  or  the  perineal  wound,  as  one 
exists,  dragging  after  it  the  conical  tampon  of  gauze. 

Sepsis. — This  may  follow  partly  from  lowered  resistance  on  account 
of  the  age  of  the  patient  or  from  a  previous  dirty  condition  of  the  bladder. 
In  the  latter  case  sepsis  should  have  been  anticipated  by  preliminary 
suprapubic  drainage  and  irrigation.  If  sepsis  occurs  after  operation, 
ample  drainage  must  be  established  and  repeated  irrigations  practised. 
Boric-acid  solution  (3  per  cent.)  or  normal  salt  solution  may  be  passed 
through  the  urethra  or  the  perineal  tube  until  it  comes  out  suprapubically 
perfectly  clear.  This  should  be  repeated  as  often  as  every  two  hours 
until  acute  signs  or  symptoms  subside. 

Peritonitis  has  followed  where  the  operation  has  caused  a  perforation 
of  the  bladder-wall.  This  accident  may  easily  happen  when  a  polypoid 
tumor  is  pulled  up  from  the  fundus  and  snipped  off. 

Fistula. — In  some  cases  it  is  found  advisable  to  allow  a  suprapubic 
opening  to  persist,  as,  for  instance,  in  the  presence  of  malignant  disease. 
The  patient  may  be  up  and  about,  so  far  as  his  general  condition  will 
allow,  with  a  drainage  catheter  passing  through  the  fistula  into  the 
bladder.  This  may  discharge  into  a  large  pad  of  gauze  or  its  outer  end 
may  be  carried  into  a  rubber  urinal  strapped  about  the  waist  or 
thigh.  Dr.  Watson  has  designed  a  belt  plate  of  hard  rubber,  curved 
to  fit  the  body,  through  which  a  hole  is  bored  obliquely,  of  the  proper 
size  to  fit  the  catheter  snugly.  This  is  held  in  place  against  the  fistula 
by  a  belt  of  broad  strapping,  and  serves  to  prevent  the  drainage  catheter 
from  slipping  in  or  out. 

^  A.  T.  Cabot,  Med.  Rev.,  New  York,  Sept.  17,  1892. 


VAGINAL   CYSTOSTOMY  545 

LATERAL  CYSTOTOMY 

This  operation  for  stone  is  practically  never  done  in  the  United 
States  now,  the  perineal  or  suprapubic  routes  or  lithotrity  having  taken 
its  place.     The  lateral  wound  gapes  and  is  slow  to  heal. 

MEDIAN  PERINEAL  LITHOTOMY 

The  advantages  of  median  perineal  lithotomy  have  been  summed 
up  thus  by  Dr.  W.  T.  Briggs:  ^ 

"  (i)  It  opens  up  the  shortest  and  most  direct  route  to  the  bladder; 
(2)  it  divides  parts  of  the  least  importance;  (3)  it  is  an  almost  bloodless 
operation;  (4)  it  affords  a  passage  for  any  calculus  which  can  be  safely 
extracted  through  the  perineum;  (5)  it  affords  the  best  passage  for  the 
fragmentation  of  unusual  calculi;  (6)  it  reduces  the  death-rate  to  a 
minimum."  In  his  first  74  cases,  none  died.  Nevertheless,  this  opera- 
tion, except  when  stone  is  removed  incidental  to  perineal  prostatectomy, 
is  rarely  practised  in  x\merica.  For  after-treatment  see  Perineal  Prosta- 
tectomy, p.  528. 

Complications  and  Sequelae. — Shock. — As  a  rule,  unless  there 
has  been  much  tearing  in  the  operation,  shock  is  not  severe.  Children 
stand  it  very  well. 

Hemorrhage,  if  it  does  not  come  from  a  vessel  that  can  be  reached 
by  a  forceps  which  is  left  for  a  time  in  situ,  may  be  controlled  by  tem- 
porary packing  of  the  bladder  through  the  wound  with  gauze,  which 
may  be  soaked  in  adrenalin. 

Local  sepsis  is  the  most  common  cause  of  death,  due  to  extravasa- 
tion of  foul  urine  into  lacerated  tissues  of  the  pelvis.  Free,  almost 
ruthless,  incisions  must  be  made  to  relieve  this  condition.  Extension  of 
this  process  may  show  itself  first  or  last  as  peritonitis. 

Surgical  Kidney. — This  condition  (p.  141)  may  be  expected  after 
any  operation  on  bladder  or  urethra.  The  same  is  true  of  urethritis,  per- 
sistent fistula,  calling  for  later  operation;  incontinence  of  urine,  where 
the  prostatic  urethra  has  been  extensively  injured  during  the  removal 
of  the  stone  through  it;  sterility,  due  to  destruction  of  ejaculatory  ducts 
in  the  prostatic  urethra. 

VAGINAL  CYSTOSTOMY 

This  operation  is  of  the  greatest  value  in  the  treatment  of  obstinate 
chronic  cystitis  in  women.  It  consists  in  the  formation  of  an  artificial 
vesicovaginal  fistula  for  the  purpose  of  establishing  constant  drainage 
of  the  bladder.     It  may  be  performed  under  cocain.     Following  this 

*  Trans.  Amer.  Surg.  Assoc,  v,  127. 
35 


546  OPERATIONS   ON  THE   KIDNEY,    URETER,    AND   BLADDER 

operation  the  tub-bath  method  of  constant  irrigation,  as  devised  by  G. 
L.  Huimer,^  is  employed.  An  ordinary  bath-tub  is  used.  The  patient 
is  supported  upon  strips  of  canvas  which  are  fastened  to  the  edges  of 
the  tub  by  brass  chps.  A  space  is  left  beneath  the  vulva  for  the  out- 
flow from  the  bladder  to  escape.  The  patient  may  either  lie  down  or 
sit  up.  In  the  latter  case  the  strip  at  the  head  of  the  tub  is  drawn  tightly 
across,  and  pillows  placed  on  top  to  act  as  a  support  for  the  patient's 

back.     A  few  slats  are  placed  across  the  top  of 
the  tub  and  covered  with  bed-clothing. 

Constant  irrigation  is  maintained  from  a 
large  irrigation  jar  at  a  height  of  3  to  4  feet 
above  the  vulva,  connecting  with  a  self-retain- 
ing catheter  which  is  inserted  through  the 
urethra.  The  overflow  escapes  through  the 
cystostomy  opening.  Warm  4  per  cent,  boric- 
acid  solution  is  used  for  the  irrigation.  The 
Fig.  189.— Female  Urinal  for      patient  is  kept  in  the  tub  during  the  day,  but 

Ambulatory  Use.  .  .  .  ,       , 

goes  to  bed  at  night,  weanng  a  rubber  urmal 
(Fig.  189).  Hexamethylamin,  10  gr.  three  times  a  day,  and  the  inges- 
tion of  large  quantities  of  water,  should  be  prescribed. 

In  case  there  is  excoriation  about  the  vulva  or  the  bladder  is  very 
irritable,  the  tub  should  be  filled  with  warm  water  to  above  the  patient's 
hips,  more  being  added  when  necessary. 

The  tub  treatment  is  carried  out  until  the  exudate  disappears  from 
the  bladder-wall,  aU  vesical  irritability  has  subsided,  and  the  bladder 
is  of  approximately  normal  capacity.  After  this  the  patient  may  get 
up  and  be  allowed  to  go  about,  wearing  a  rubber  urinal.  The  cystos- 
tomy wound  is  left  open  for  six  months,  the  bladder  being  irrigated  daily. 
The  operation  for  its  closure  does  not  differ  from  that  for  any  vesico- 
vaginal fistula  (Chap.  XLYI,  p.  475).     Neither  does  the  after-treatment. 

The  diet  should  be  largely  liquid.  Tea,  coffee,  alcohol,  and  condi- 
ments are  forbidden. 

The  bowels  are  best  attended  to  at  night  if  the  actual  bath  is  used. 
They  should  move  at  least  once  in  every  twenty-four  hours. 

EXSTROPHY   OF  BLADDER 

Plastic  Operations. — These  operations,  all  more  or  less  variations 
of  the  type  of  Mr.  Wood,-  for  the  time  being  require  the  anterior  surface 
of  the  body  to  be  somewhat  flexed  to  prevent  pulling  on  the  flaps.    After 

1  G.  L.  Hunner,  "The  Tub-bath  Treatment  of  Cystitis,"  Jour.  Amer.  Med.  Assoc, 
1907,  xli.x,  2066.  ^  Med.  Chir.  Transactions,  London,  lii,  85. 


EXSTROPHY   OF   BLADDER  547 

the  operation  the  patient  should,  therefore,  be  kept  propped  up  in  bed, 
the  shoulders  rounded  over  forward,  and  the  knees  flexed.  A  broad 
flannel  strap  or  bandage,  passed  under  the  knees  and  over  the  shoulders, 
will  surely  prevent  sudden  extension  of  the  body.  Unless  there  is  a 
definite  contraindication,  the  patient  should  be  kept  quiet,  even  to 
stupidity,  with  morphin.  The  wounds  should  be  dressed  frequently 
and  drainage  of  the  newly  formed  bladder,  with  frequent  washings, 
maintained  for  at  least  ten  days. 

Cystocolostomy  {MaydVs  Operation). — By  this  operation  the 
trigone  of  the  ectopic  bladder,  with  its  ureteral  orifices,  is  transplanted 
into  the  wall  of  the  sigmoid. 

"A  boy  five  years  old  was  operated  on  in  May,  1897.  In  March,  1898,  his 
condition  was  reported  by  the  operator  as  admirable.  Quantity  of  urine, 
1000-1200  CO.  in  twenty-four  hours;  specific  gravity,  1.013;  slight  amount  of 
albumin;  no  pus.  The  boy  was  able  to  hold  urine  five  hours  at  a  time,  and 
then  to  eject  it  in  a  good  stream  from  the  rectum.  In  August,  1899  (a  year 
and  a  half  after  the  operation) ,  the  condition  continued  as  satisfactory.  The 
patient,  now  a  rapidly  growing  and  strengthening  boy,  enjoyed  living,  retaining 
his  urine  for  six  or  seven  hours  during  the  daytime,  but  relieving  himself  often 
at  night  or  running  the  risk  of  wetting  the  bed  while  in  deep  sleep."  * 

Complications  and  Sequelae. — In  17  operations  there  were  2 
deaths — one  from  shock  and  the  other  from  infection.  "The  secondary 
accidents  noted  were — 

"  (i)  Fistula  of  the  urinary  passages,  wdth  the  accompanying  local- 
ized peritonitis,  all  of  which  cases  recovered. 

"  (2)  Pyelonephritis,  as  the  result  of  ascending  invasion,  resulted  in 
the  death  of  one  case  after  a  period  of  four  months. 

"  (3)  Urinary  incontinence  was  present  in  only  2  cases.  The  other 
patients  were  able  to  hold  their  urine  for  at  least  three  hours,  sometimes 
six  or  seven  hours,  and  in  i  case  throughout  the  night.  The  urine  w^as 
voided  ■sometimes  mixed  with  fecal  matter,  sometimes  alone.  The 
tolerance  of  the  rectal  membrane  was  perfect. 

"In  spite  of  the  fact  that  this  operation  is  undoubtedly  far  more 
severe  than  the  plastic  operation,  the  immediate  results  are  extremely 
good  and  far  better  than  those,  of  the  older  methods.^  Time  alone  can 
settle  the  question  as  to  whether  destruction  of  the  kidneys  from  ascend- 
ing inflammation  will  be  a  more  common  late. result  than  after  a  plastic 
operation."  ^ 

^  Herczel,  Centralbl.  d.  Harn-  u.  Sexorg.,  1899,  563. 
^  See  Bransford  Lewis,  Ann.  Surg.,  June,  1900,  xxxi. 
^  Jacobson  and  Steward,  ii,  448. 


CHAPTER  XLIX 

OPERATIONS  ON  ANUS  AND  RECTUM 

FISSURE  IN  ANO 

Thorough  dilatation  of  the  sphincter  under  a  general  anesthetic 
cures  this  condition.  There  may  be  enough  infection  in  the  fissure  to 
spread  into  the  deeper  tissues  after  dilatation  and  cause  a  perineal  or 
an  ischiorectal  abscess.  The  first  movements  after  this  operation  should 
be  assisted  by  oil  enemas. 

FISTULA  IN  ANO 

In  this  disease,  whether  tuberculous  or  not,  all  attempts  to  sew  up 
the  wound,  even  after  the  most  thorough  treatment  with  antiseptics, 
so  often  fail  that  it  will  be  assumed  that  the  common  operation  of  cutting 
through  the  fistulous  tract  and  through  the  external  sphincter  muscle 
into  the  anal  canal,  with  or  without  excision  of  the  lining  of  the  fistulous 
tract,  has  been  performed.  The  wound  should  be  painted  with  full -strength 
tincture  of  iodin,  packed  with  iodoform  gauze,  and  a  fairly  stiff  soft-rubber 
tube,  surrounded  by  gauze  and  rubber  tissue  (Fig.  85,  p.  220),  passed 
through  the  thoroughly  dilated  sphincter  up  into  the  rectum,  as  in  the 
case  of  operation  for  hemorrhoids.  Postoperative  pain  and  spasm 
may  be  forestalled  by  inserting  one  or  two  morphin  and  belladonna  sup- 
positories into  the  anal  canal  before  the  patient  leaves  the  table. 

On  the  second  day  this  rectal  plug  should  be  extracted,  some  aperient 
water  given,  and,  after  the  movement,  the  wound  thoroughly  cleaned, 
again  painted  with  tincture  of  iodin,  and  lightly  packed  with  iodoform 
gauze.  This  procedure  of  bowel  movement,  followed  by  cleaning  and 
dressing,  is  to  be  done  daily,  care  being  taken  not  to  get  the  iodin  on  the 
surrounding  skin. 

After  the  second  day  the  patient  should  be  out-of-doors,  but  still 
reclining,  all  day  if  possible.  These  wounds,  tuberculous  or  not,  heal 
much  better  out-of-doors.  The  ideal  conditions  are  to  have  the  patient 
on  the  roof  or  in  some  other  isolated  place,  where  the  region  of  the 
wound  can  be  exposed  to  direct  sunlight,  just  short  of  excessive  sunburn, 
daily. 

548 


ISCHIORECTAL   ABSCESS  549 

The  patient  should  be  up  and  about  by  the  fifth  day  unless  the 
wound  is  unusually  large.  If  the  fistula  is  not  extensive,  and  if  condi- 
tions are  such  that  the  patient  must  be  gotten  back  to  his  work  as  soon 
as  possible,  the  daily  dressing  with  tincture  of  iodin  may  be  omitted  as 
soon  as  it  is  evident  that  the  fistulous  tract  is  granulating  in  well,  and 
the  patient  given  suppositories  of  iodoform  and  tannic  acid,  of  each, 
I  gr.,  to  be  inserted  twice  daily  after  cleansing  the  part.  The  bowels 
should  be  kept  semifluid  for  some  days.  Control  of  the  rectal  contents 
should  be  satisfactory  by  the  fifth  day  unless— (i)  the  external  sphincter 
were  cut  in  two  places  (a  bad  procedure,  if  at  all  avoidable);  (2)  the 
internal  sphincter  has  been  cut;  (3)  the  cut  has  extended  through  the 
vaginal  sphincter.  Control  does  reappear  in  many  cases  even  when  the 
operation  has  made  one  of  these  procedures  necessary,  but  complete 
control  can  never  be  promised,  and  operative  repair  of  the  sphincter 
is  sometimes  necessary. 

Healing  of  these  wounds  seems,  more  than  in  many  other  kinds  and 
situations,  to  depend  to  a  great  degree  on  the  general  condition  of  the 
patient.  In  tincture  of  iodin  we  have  undoubtedly  the  best  antiseptic 
and  stimulant  for  the  region. 

IMPERFORATE  ANUS;  IMPERFORATE  RECTUM 
Unless  the  operation  attempting,  first,  to  connect  the  rectum  with 
the  anal  depression  or,  second,  to  connect  the  rectum  with  an  artificial 
anus  in  the  normal  situation,  succeeds  at  once  and  remains  perforate, 
an  inguinal  colotomy  must  be  made.  In  either  case  the  problems  in- 
volved in  the  treatment  are  the  same  as  in  colotomy,  at  first  at  least. 

ISCHIORECTAL  ABSCESS 

The  abscess-cavity  is  wiped  out  dry.  Tincture  of  iodin  is  painted 
over  the  whole  lining  wall,  including  the  incision  through  the  sphincter, 
if  one  has  been  made.  The  wound  is  packed  with  10  per  cent,  iodoform 
gauze  to  distend  it  and  render  it  into  one  cavity  without  pockets.  A 
suppository  of  morphin  and  belladonna,  of  each,  I  gr.,  is  placed  in  the 
rectum;  a  voluminous  dry  dressing  is  held  on  by  a  T-bandage. 

The  original  packing  need  not  be  changed  in  most  cases  until  the 
third  or  fourth  day.  It  is  then  entirely  rem^oved,  tincture  of  iodin 
again  applied  inside,  and  a  smaller  drainage  wick  of  iodoform  gauze 
inserted.  '  The  dressing  is  now  done  daily,  but  the  iodin  need  only  be 
used  every  third  day.  Direct  sunlight  on  the  wound,  if  practicable, 
greatly  advances  the  healing.  An  emollient  is  kept  round  the  anus  and 
edges  of  the  wound. 


550  OPERATIONS  ON  ANUS  AND  RECTUM 

The  patient  is  out  of  bed  as  soon  as  he  can  sit  on  an  inflated  rubber 
rins  without  too  much  discomfort.  The  bowels  are  moved  daily  from 
the  beginning. 

Complications  and  Sequelse. — Spread  of  Infection. — Cases  in 
which  the  incisions  are  to  any  degree  inefi&cient  in  position  or  size  may 
form  new  pockets;  the  infection  may  spread  completely  over  the  but- 
tock or  fonvard  into  scrotum  or  labium  majus;  from  the  rectum  may 
appear  a  secondary  infection  with  tetanus  or  the  gas  bacillus  (bacillus 
aerogenes  capsulatus),  even  resulting  fatally. 

Retention  of  urine  may  be  bothersome  for  a  few  days,  as  after  any 
rectal  operation. 

Loss  of  sphincter  control  will  not  appear  if  the  muscle  has  been  cut 
only  once;  if  more  than  one  incision  through  it  has  been  made,  a  secon- 
dary operation  may  be  necessary  weeks  or  months  later  to  restore  its 
integrity. 

Recurrences  are  not  uncommon.  In  view  of  the  theory  that  a  certain 
percentage  of  cases  are  associated  with  tuberculosis,  it  is  well  to  take 
measures  to  combat  any  tendency  to  this  disease. 

HEMORRHOIDS 

Clamp  and  Cautery  Operation. — It  is  understood  that  the 
sphincter  has  been  absolutely  paralyzed  by  thorough,  slow  dilatation. 
The  hemorrhoid  masses  have  been  burned  off  along  lines  parallel  to 
the  axis  of  the  anal  canal,  all  immediate  hemorrhage  has  been  stopped, 
a  gauze  plug,  containing  a  fairly  stiff  soft-rubber  tube  in  its  center  for 
the  passage  of  gas,  and  Avrapped  in  rubber  dam,  has  been  placed  in  the 
rectum,  protruding  from  it.  A  T-bandage  holds  the  dressing  firmly 
against  the  parts.  Before  the  rectal  plug  has  been  inserted  at  the  end 
of  the  operation  a  suppository  containing  \  \.o  \  gr.  morphin  sulphate 
and  \  gr.  extract  of  belladonna  has  been  inserted. 

Uncomplicated,  there  is  inevitably  considerable  pain,  which  should 
be  controlled  by  the  administration  of  morphin.  There  should  be  no 
bleeding.  Surgeons  are  at  variance  on  the  question  as  to  whether  or  not 
one  should  use  the  rectal  plug.  Personally,  I  cannot  see  any  notable 
difference  in  the  convalescence  either  way,  particularly  if  the  original 
dilatation  of  the  sphincter  has  been  complete. 

Similarly,  if  the  piles  have,  been  burned  from  a  dilated  anus,  there 
can  be  no  ground,  on  the  plea  of  insufficient  healing,  to  prevent  a  move- 
ment of  the  bowels  for  from  fiA-e  to  seven  days.  Best  results,  indeed, 
seem  to  follow  early  movement  of  the  bowels ;  the  packing  of  the  lower 
bowel  with  fecal  matter  retained  for  scA'eral  days  tends  to  produce  con- 


HEMORRHOIDS  55 1 

gestion  in  the  recently  operated  area.  Two  Seidlitz  powders  or  a  dose 
of  castor  oil  is  given  on  the  third  day,  and  when  the  desire  for  a  move- 
ment comes,  6  or  8  ounces  of  warm  sweet  oil  are  injected  through  a 
tube  passed  4  or  5  inches  up,  in  order  to  soften  the  presenting  fecal 
mass.  The  first  movement  should  then  be  easy,  though  pain  is  some- 
times so  severe  that  the  patient  faints,  and  for  this  possibility  the  nurse 
should  watch.  After  each  movement  and  morning  and  night  for  a 
week  a  suppository  containing — 

Iodoform, i  gr. 

Tannic   acid i  gr. 

Cocoa-butter q.  s. 

should  be  inserted  within  the  rectum.  After  a  week  one  such  suppository 
should  be  used  after  each  movement. 

The  patient  should  stay  in  bed  a  full  week,  first,  because  recumbency 
is  the  most  comfortable  position,  and,  second,  because  of  possible  com- 
pHcations. 

Ungue?itum  gallcB  cum  opio  (B.  P.)  is  an  excellent  ointment,  applied 
at  night  and  after  each  movement  to  the  whole  anal  region,  to  help 
shrink  away  external  redundant  tissue. 

Complications  and  Sequelae. — Hemorrhage.  —  Bleeding  may 
occur  because  the  clamp  has  bitten  too  deeply  into  the  submucous  tissue, 
or  too  much  has  been  included  in  the  clamp  and  the  wound  separates 
shortly  afterward.  Bleeding  is  likely  also  if  the  cautery  has  been  too 
hot,  cutting  the  piles  off  too  cleanly,  leaving  no  eschar.  If  the  hemor- 
rhage is  considerable,  an  attempt  may  be  made  to  control  it  by  packing. 
If  it  is  arterial,  this  will  probably  fail  and  the  patient  must  be  put  in 
the  lithotomy  position,  the  bleeding  point  found,  clamped,  and  tied. 

Embolism. — Fatal  embolism  has  been  reported  at  any  time  up  to 
the  eighth  day  after  this  operation,  though  it  is  more  likely  after  ligature. 
Treatment  is,  of  course,  of  no  avail,  but  the  possibility  of  this  occurrence 
should  be  always  in  mind  when  giving  a  prognosis  of  this  relatively 
unimportant  disease  and  in  allowing  the  patient  to  get  out  of  bed  too 
early. 

Sepsis. — Dilatation  of  the  sphincter  may  cause  numerous  fissures, 
any  one  of  which  may  become  infected,  and  even  lead  to  a  large  ischio- 
rectal abscess.  Sepsis  may,  in  persons  in  reduced  condition,  take  the 
form  of  a  prolonged  ulceration  of  the  several  stumps.  This  should  yield, 
however,  to  good  hygiene  and  the  suppositories  as  above. 

Stricture  of  the  Rectum. — This  after-effect  is  practically  unknown 
after  a  careful  operation,  but  may  occur  where  the  clamp  has  not  protected 


552  OPERATIONS  ON  ANUS  AND  RECTUM 

underlying  tissues  from  the  cautery.  It  can  be  met  and  controlled  by 
repeated  use  and  slow  passage  of  a  rectal  bougie. 

Retention  of  Urine. — In  operations  about  the  anterior  quadrants 
of  the  rectum  one  should  always  bear  in  mind  the  possibility  of  injuries 
to  the  urethra,  and  also  the  fact  that  much  manipulation  and  trauma- 
tism of  these  parts  may  result  in  an  acute  irritation  of  the  peri-urethral 
tissues,  which  will  cause  a  temporary  edema  and  constriction  of  the 
urethral  canal.  In  such  cases  it  will  sometimes  be  found  impossible 
to  pass  an  ordinary  soft-rubber  or  flexible  catheter  into  the  bladder, 
and  one  should  always  be  provided  with  a  silver  catheter  in  order  to  be 
able  to  draw  the  urine.  As  soon  as  the  distention  subsides,  these  sug- 
gestions of  stricture  rapidly  disappear.  It  is  advisable  to  induce  the 
patient  to  urinate  before  attempting  to  catheterize  him  if  possible,  even 
if  he  has  to  stand  on  his  feet  to  do  so.  It  is  well  to  wait  for  from  four 
to  fourteen  hours  before  resorting  to  the  catheter,  only  varying  this  rule 
in  such  cases  as  suffer  from  distention  of  the  bladder.  A  certain  amount 
of  cystitis  and  atony  of  the  bladder  may  be  developed  by  too  long  delay, 
but  it  much  more  frequently  occurs  as  a  result  of  too  frequent  and 
too  early  catheterization,  even  under  the  most  particular  aseptic  precau- 
tions. The  catheter  may  be  perfectly  sterilized  and  the  operator  as 
clean  as  antiseptics  can  make  him,  and  yet,  as  the  walls  of  the  anterior 
and  deep  urethra  cannot  be  sterilized,  slight  traumatism,  such  as  may 
be  produced  by  the  softest  instrument,  will  sometimes  set  up  an  attack 
of  urethritis  and  cystitis  which  will  take  months  to  clear  up. 

Firm  packing  of  the  rectum  may  cause  retention  of  urine,  and  some- 
times even  render  the  passage  of  the  catheter  impossible.  When  this 
occurs,  the  dressings  should  be  removed,  and  frequently  after  this  is  done 
the  patient  can  pass  urine  voluntarily.  In  all  cases  before  the  catheter  is 
passed  the  anterior  urethra  should  be  flushed  with  boric-acid  solution. 

Treatment  by  I/igature. — This  operation  is  used  relatively 
little  in  America,  and  in  the  after-care  arise,  as  a  rule,  only  t^vo  com- 
plications: (i)  Hemorrhage.  If  the  ligature,  insecurely  placed  or  tied 
around  too  wide  a  base,  slip  sufficiently,  hemorrhage  may  take  place  and 
require  the  application  of  a  hemostatic  forceps,  to  be  left  in  position. 
(2)  Pain  after  this  operation  may  call  for  considerable  amounts  of 
morphin. 

Whitehead's  Operation.i— in  this  operation,  after  dilatation, 
the  whole  pile-bearing  area  is  cut  away  in  a  cuff  or  cylinder  and  the 
edge  of  mucous  membrane  is  sewed  down  to  the  skin  with  interrupted 
chromic  catgut  sutures.     If  the  continuous  suture  is  used,  one  suture 

1  Brit.  Med.  Jour.,  Feb.  26,  1S87. 


KRASKE  S  OPERATION  FOR  CANCER  OF  THE  RECTUM      553 

should  not  go  more  than  a  third  of  the  way  round  the  circle,  lest  the 
^^•hole  act  as  a  purse-string.  Catharsis  should  be  regulated  as  after  the 
cautery  operation,  and  the  same  directions  hold  with  regard  to  anti- 
septics, iodoform  being  the  best  dressing. 

The  possibility  of  stricture  after  this  operation  is  always  to  be  men- 
tioned. If  the  operation  is  done  properly,  namely,  excising  only  mucosa, 
not  removing  too  wide  a  cuff,  and  stitching  with  great  care,  stricture  will 
not  occur. 

Hemorrhage,  which  is  sometimes  supposed  to  be  a  comxmon  complica- 
tion of  this  operation,  should  not  occur  if  ordinary  precautions  are 
taken  to  tie  off  bleeding  points  before  completing  the  operation  by 
sewing  down  the  amputated  mucosa  to  the  anal  margin.  Pain  may  be 
severe  in  a  certain  number  of  cases;  it  seems  to  be  dependent,  in  some 
measure  at  least,  on  tightly  drawn  sutures.  It  will  be  less  if  the  sphinc- 
ter has  been  sufficiently  stretched  as  to  become  paretic,  and  if  a  morphin 
and  belladonna  suppository  has  been  inserted.  It  yields  rapidly  to 
hot  boric  fomentations  applied  locally.  Bishop  ^  recommends  the 
early  administration  of  gentle  laxatives,  such  as  cascara  and  licorice 
powder,  after  operation,  so  as  to  forestall  the  formation  of  hard  masses, 
such  as  might  in  their  passage  cause  damage  by  tearing  and  splitting 
the  partly  healed  tissues. 

PROLAPSE  OF  RECTUM 

The  after-treatment  of  this  condition  differs  in  no  way  from  that  of 
Whitehead's  operation  for  hemorrhoids  (see  above). 

KRASKE'S  OPERATION  FOR  CANCER  OF  THE  RECTUM 

Access  to  the  rectum  by  resection  of  the  sacrum  was  first  described 
by  Kraske  in  1885  before  the  Deutsche  Gesellschaft  fiir  Chirurgie. 
Since  the  publication-  of  his  original  article  his  method  has  been  modified 
by  a  large  number  of  operators.  As  these  operations  differ  from  Kraske's 
only  in  minor  ways,  the  after-treatment  of  all  is  essentially  the  same, 
therefore  it  will  be  understood  that  what  is  said  here  concerning  the 
Kraske  operation  applies  equally  to  all  other  methods  of  excision  of  the 
rectum  by  the  sacral  route. 

The  operation  should  be  preceded  by  a  few  days  of  careful  pre- 
liminary treatment,  diminishing  as  far  as  possible  the  intestinal  contents 
by  enemas,  catharsis,  and  a  diet  consisting  of  liquids  without  milk. 


^  Brit.  Med.  Jour.,  Oct.  30,  1909. 

^  Archiv  f.  klin.  Chir.,  1S86,  xxxiii,  563. 


554  OPERATIONS   ON   ANUS   AND   RECTUM 

As  in  all  rectal  operations,  the  sphincter  ani  must  be  thoroughly  stretched 
before  the  operation  is  begun.  The  method  of  choice  in  dealing  with 
the  bowel  after  resection  of  the  portion  containing  the  growth  is  end-to- 
end  anastomosis  of  the  proximal  and  distal  portions.  When  this  can 
be  satisfactorily  accomplished,  the  rectum  is  packed  through  the  anus 
with  gauze  surrounding  a  rubber  tube  which  is  passed  up  beyond  the 
point  of  suture.  The  rubber  tube  allows  the  passage  of  gas  and  the 
gauze  pack  protects  the  line  of  suture.  If  the  peritoneal  cavity  has 
been  opened,  the  peritoneum  is  united  to  the  serous  coat  of  the  bowel 
except  for  a  small  opening  through  which  is  passed  a  gauze  wick.  A 
second  gauze  drain  is  so  passed  into  the  wound  as  to  surround  the  line 
of  anastomosis,  and  the  remainder  of  the  incision  closed  with  silkworm- 
gut  sutures.  A  large  sterile  gauze  dressing  is  placed  over  the  wound 
and  held  in  position  by  adhesive  straps,  outside  of  which  a  swathe  and 
T-bandage  are  worn. 

The  patient  is  put  to  bed  lying  on  his  side  and  I  gr.  of  morphin  is 
given  hypodermically  before  he  comes  out  of  ether.  The  diet  during 
the  first  ten  days  should  consist  of  liquids  without  milk.  On  the  fourth 
day  the  dressing  is  done,  the  wicks  removed,  and  replaced  by  smaller 
ones.  The  gauze  and  tube  are  removed  from  the  rectum  and  the 
bowels  opened  by  an  oil  enema  ^  retained  one -half  hour  and  followed 
by  a  copious  irrigation  of  plain  water.  The  stools  are  now  kept  liquid 
by  the  daily  administration  of  salines,  oil  enemas  being  given  whenever 
there  is  the  slightest  tendency  for  the  feces  to  become  hard.  The  gauze 
pads  on  the  wound  should  be  changed  after  each  movement.  The  wicks 
may  usually  be  omitted  on  the  fifth  day.  If  there  is  much  discharge 
from  the  sinus,  it  should  be  irrigated  daily  with  chlorinated  soda  solution 
(i :  80) .     The  stitches  are  taken  out  on  the  tenth  day. 

If  the  patient  is  old  or  in  poor  physical  condition,  he  should  be  got 
out  of  bed  into  a  chair  at  the  end  of  forty-eight  hours.  Otherwise  he 
will  be  more  comfortable  in  bed  for  ten  days.  After  the  tenth  day  soft 
solids  may  be  added  to  the  diet.  Full  diet  is  begun  at  the  end  of  two 
weeks.  After  the  first  ten  days  the  bowels  are  kept  moderately  free  by 
catharsis.     Oil  enemas  are  no  longer  necessary. 

The  rectum  must  be  examined  at  frequent  intervals  after  this  opera- 
tion to  detect  recurrence  of  stricture  from  contraction  of  the  scar.  This 
inspection  should  be  made  at  least  twice  every  month  for  six  months, 
then  once  each  month  for  the  remainder  of  the  first  year,  and  at  least 

^  Care  must  be  exercised  in  introducing  the  rectal  tube.  A  case  has  come  to  my  notice 
where  fatal  peritonitis  resulted  from  the  nurse  forcing  the  tube  through  the  line  of  sutures 
into  the  peritoneal  cavity. 


KRASKE  S  OPERATION  FOR  CANCER  OF  THE  RECTUM       555 

once  in  three  months  until  five  years  have  elapsed  from  the  time  of 
operation. 

Where,  as  often  happens,  it  is  impossible  to  unite  the  bowel  ends 
after  resection,  the  proximal  end  is  sutured  to  the  skin  of  the  sacral 
incision,  making  a  sacral  anus.  A  wick  is  passed  into  the  peritoneal 
cavity,  which  is  always  opened  under  these  circumstances,  above  this 
anus,  and  a  second  into  the  postrectal  tissues  below  it.  The  remainder 
of  the  incision  is  closed  with  silkworm-gut.  The  wicks  are  removed 
and  omitted  on  the  fourth  day.  The  stitches  are  taken  out  on  the  tenth 
day.  The  artificial  anus  is  treated  the  same  as  one  in  the  anterior 
abdominal  wall. 

Complications  and  Sequelae. — Infection. — This  is  the  most 
common  complication,  and  often  leads  to  sloughing  of  the  line  of  suture 
in  the  bowel,  resulting  in  a  fecal  fistula. 

Fecal  Fistula. — ^When  a  fistula  develops  in  the  sacral  wound,  the  gauze 
must  be  removed  from  the  rectum  and  the  wicks  taken  out  of  the  wound. 
The  sinuses  and  fistula  should  be  irrigated  twice  daily  with  a  i :  80 
solution  of  chlorinated  soda.  The  skin  about  the  fistula  is  smeared  with 
10  per  cent,  stearate  of  zinc  ointment  and  a  large  absorbent  pad,  fre- 
c[uently  changed,  is  used  to  catch  the  discharge  from  the  wound.  The 
fistula  usually  closes  spontaneously,  but  if  it  does  not  after  waiting  for 
three  months,  it  must  be  closed  by  operative  means. 

Injury  to  Adjace^it  Organs. — The  bladder,  urethra,  prostate,  or  semi- 
nal vesicles  may  be  injured,  and  if  not  repaired,  may  result  in  a  fistula 
between  the  rectum  and  the  genito-urinary  tract,  which  is  likely  to  carry 
infection  to  the  bladder  and  kidneys.  Injury  to  the  vagina  may  result 
in  a  rectovaginal  fistula  which,  however,  as  a  rule,  will  close  spontaneously 
unless  recurrence  takes  place  in  its  walls. 

Disturbances  of  the  Urinary  Tract. — ^These  may  be  slight  and  transi- 
tory as  a  result  of  pressure  of  the  dressings,  or  reflex  irritation  from 
the  trauma  of  the  operation,  or  they  may  be  so  severe  as  to  result  in 
uremia. 

Hemorrhage. — This  is  rare.  If  not  controlled  by  packing  in  the 
wound  and  rectum,  the  incision  must  be  reopened  and  the  bleeding 
point  found  and  ligated. 

Stricture  of  the  Rectum. — This  is  to  be  anticipated  by  frequent  in- 
spection of  the  rectum  and  the  passage  of  rubber  bougies  whenever  any 
tendency  toward  narrowing  of  the  lumen  appears. 

Incontinence  of  Feces. — This  is  to  be  avoided  whenever  possible 
by  preserving  the  external  sphincter  at  operation.  When  it  is  necessary 
to  sacrifice  the  sphincter,   incontinence   may  be  avoided,   or  at  least 


556  OPERATIONS  ON  ANUS  AND  RECTUM 

diminished,  by  Gersuny's  method,  which  consists  in  twisting  the  bowel 
180  to  275  degrees  on  its  long  axis  before  suturing  it  to  the  skin,  or  by 
the  method  of  Willem,  in  which  the  rectum  is  brought  out  through  the 
fibers  of  the  gluteus  maximus,  which  serves  as  a  new  sphincter. 

Recurrence. — When  there  seems  to  be  a  chance  of  entirely  removing 
it,  the  attempt  should  be  made  to  excise  the  recurrent  growth.  If  this 
fails  or  appears  impossible,  palliative  treatment  directed  to  the  patient's 
comfort  should  be  instituted. 

WEIR'S  COMBINED  OPERATION  FOR  CANCER  OF  THE  RECTUM 

This  operation,  described  by  Weir  in  1900,^  consists  in  the  abdominal 
resection  of  the  rectum  completed  by  suture  of  the  cut  ends,  which  are 
both  drawn  down  through  the  anus,  outside  of  the  body.  The  bowel 
is  then  returned  inside  the  pelvis,  the  peritoneum  over  the  pelvis  and 
the  abdominal  wound  in  the  mean  while  having  been  closed  without 
drainage.  An  incision  is  made  through  the  skin  between  the  tip  of  the 
coccyx  and  the  anus,  and  a  rubber  drainage-tube  passed  through  this 
into  the  postrectal  space  as  high  as  the  peritoneum.  A  rubber  tube 
surrounded  by  gauze  is  then  passed  up  inside  the  rectum  until  its  upper 
end  lies  above  the  line  of  suture.  The  anus  and  postrectal  wound  are 
covered  with  a  large  sterile  pad,  held  in  position  by  a  T-bandage.  Both 
tubes  are  removed  on  the  fourth  day,  the  rectal  tube  omitted,  and  the 
postrectal  shortened.  The  postrectal  tube  is  shortened  daily  and 
usually  may  be  omitted  on  the  ninth  day  The  abdominal  wound  is 
simply  dressed  with  sterile  gauze  and  left  undisturbed  until  the  tenth 
day,  when  the  stitches  are  removed. 

The  patient  is  kept  on  a  diet  of  liquids  without  milk  throughout  the 
convalescence.  In  the  absence  of  distention  the  bowels  are  not  moved 
until  the  ninth  day.  Calomel  is  given  the  evening  before  the  eighth, 
and  on  the  morning  of  the  ninth  a  high  oil  enema,  retained  one-half  hour, 
followed  by  a  high  suds  enema.  After  this  the  bowels  are  kept  open 
by  daily  catharsis.  The  patient  is  allowed  to  sit  up  in  bed  on  the  eighth, 
and  get  up  on  the  tenth,  day.  The  subsequent  care  of  the  patient  is 
the  same  as  described  for  Kraske's  operation. 

Complications  and  Sequelae. — Peritonitis,  shock,  secondary 
hemorrhage,  and  other  complications  common  to  all  celiotomies,  may 
occur  and  should  be  treated  by  appropriate  measures. 

Distention. — Every  effort  should  be  made  to  control  distention  by 
hot  applications  and  the  careful  passage  of  a  small  rectal  tube  or  large 
catheter  up  through  the  rubber  tube  in  the  rectum  into  the  sigmoid. 

^  Jour.  Amer.  Med.  Assoc,  1901,  xxwii,  801. 


VAGINAL   PROCTECTOMY  557 

If  these  fail,  catharsis  should  be  resorted  to,  and  the  use  of  enemas  as  a 
last  resort. 

Infection  in  the  perirectal  tissues  may  result  in  a  fecal  fistula  dis- 
charging through  the  postanal  wound,  but  this,  if  simply  kept  clean 
by  irrigations  with  chlorinated  soda  solution,  will  usually  close  spon- 
taneously. 

Injury  to  adjacent  organs  should  be  less  common  than  after  Kraske's 
operation,  since  in  this  procedure  the  dissection  is,  for  the  most  part, 
carried  out  under  the  eye. 

Of  disturbances  of  the  urinary  tract,  stricture  of  the  rectum,  recur- 
rence and  incontinence  of  feces,  that  which  has  already  been  said  under 
Kjaske's  operation  applies  here. 

The  after-treatment  of  the  other  methods  of  combined  operations, 
including  the  elaborate  technique  lately  described  by  W.  C.  Lusk,^  is 
identical  with  that  described  for  Weir's  operation. 

VAGINAL  PROCTECTOMY 

This  is  the  method  of  choice  for  the  removal  of  cancer  of  the  rectum 
in  the  female.  The  vaginal  wound  is  closed  with  heavy  catgut  or  with 
silkworm  gut  except  at  its  upper  portion,  where  a  small  drain  is  inserted 
if  the  peritoneal  cavity  has  been  opened.  A  rubber  tube  surrounded 
with  gauze  is  passed  into  the  rectum  through  the  anus  and  carried  above 
the  line  of  suture.  This  and  the  vaginal  wick  are  removed  on  the  fourth 
day  and  entirely  omitted.  The  stitches  are  removed  on  the  tenth  day. 
Other  details  of  treatment  are  exactly  similar  to  those  described  for 
Kraske's  operation. 

^  Surg.,  Gyn.  and  Obstetrics,  1908,  vii,  113,  also  ibid.,  1909,  ix,  491. 


CHAPTER  L 

OPERATIONS  ON  THE  EXTREMITIES 

AMPUTATIONS 

In  general,  where  the  wounds  are  sewed  tight,  they  present  no  dis- 
tinctions from  other  simple  incised  wounds.  If,  on  account  of  oozing 
from  muscles,  rubber  dam,  tube,  or  gauze  temporary  drainage  has 
been  put  in,  this  may  be  withdrawn  at  the  end  of  twenty-four  hours 
and  the  provisional  suture  tied.  The  sutures  should  be  left  in  a  full 
ten  days,  and  after  their  removal  the  wound  should  be  reinforced  by 
two,  three,  or  more  zinc-oxid  plaster  strips,  so  narrow  that  they  will  not 
cover  the  whole  wound,  but  long  enough  to  distribute  the  strain  of  the 
end  of  the  stump  along  the  length  of  the  limb.  A  splint  is  applied  to  the 
stump,  protruding  to  protect  the  end.     A  cradle  holds  the  bed-clothes  up. 

The  stay  in  bed  is  from  ten  days  to  a  number  of  weeks,  according 
to  the  nature  and  healing  of  the  wound. 

Complications  and  Sequelae. — Sepsis  may  be  met  by  drainage 
through  the  wound  opening,  as  little  of  it,  however,  as  will  insure  efficient 
outlet.  A  persisting  sinus  means  either  a  deep-lying  infected  ligature 
or  necrotic  bone.  The  latter  may  be  only  unremoved  splinters  of  bone 
or  may  be  the  cut  end.  Thirteen  to  sixteen  weeks  should  be  given, 
however,  before  any  secondary  operation  is  undertaken,  unless  special 
indications  arise.  During  this  period  splinters  and  small  chips  of  bone 
will  ordinarily  separate  and  come  out. 

Thrombosis  and  Emholism. — In  patients  with  arteriosclerosis  or  other 
cardiovascular  disease,  including  myocarditis,  in  patients  suffering 
profoundly  from  shock,  in  cases  of  infected  wounds,  and  in  other  condi- 
tions, thrombosis  is  always  a  possibility.  When  this  occurs,  with  its 
cyanosis,  edema,  or  threatened  gangrene,  the  treatment  is  largely  ex- 
pectant. The  limb  must  be  kept  warm,  slightly  elevated,  and  all  sudden 
movements  must  be  especially  prevented,  lest  embolism  occur. 

Painful  Stump. — This  diagnosis  must  not  be  made  too  quicldy. 
Every  newly  healing  bone  or  scar  is  somewhat  sensitive,  and  the  degree 
of  sensibility  varies  with  the  character  of  the  individual.  A  scar  badly 
placed,  in  such  a  way  that  it  bears  against  the  clothes,  bandage,  or 
apparatus,  causes  a  kind  of  painful  stump.     The  expression,  however, 

558 


AMPUTATIONS  559 

is  properly  applied  to  a  stump  in  which  a  severed  nerve  or  nerves  are 
caught  in  the  scar,  and  to  cases  where  the  flaps  are  too  short  and  are 
adherent  to  the  bone  in  such  a  manner  that  pressure  or  pull  causes  pain. 
For  all  degrees  of  sensitiveness  not  due  to  the  last  two  causes,  massage 
with  cold  cream,  wintergreen  oil,  zinc-oxid  ointment,  or  some  other 
such  emollient  preparation,  together  with  hot  and  cold  sprays  and 
exposure  to  the  sun,  will  quickly  harden  the  stump.  Fairly  tight  applica- 
tion of  a  Shaker  flannel  bandage,  or  a  so-called  "horse"  bandage, 
will  help  to  cause  atrophy  of  the  stump,  help  it  to  assume  the  ultimate 
form  for  the  artificial  limb  socket,  and  prevent  edema.  Under  such 
bandaging,  also,  sensitiveness  not  due  to  an  organic  cause  will  rapidly 
diminish.  If  these  all  fail  to  relieve  the  condition,  further  operation 
must  be  done — either  removal  of  an  inch  or  more  of  bone  or  the  dis- 
section out  of  the  nerve-ends  and  their  removal. 

Amputations  of  the  Shoulder  and  Shoulder-girdle. — The 
dressing  after  either  of  these  operations  is  held  in  place  by  adhesive 
straps  and  a  bandage  or  swathe  passing  about  the  chest  and  over  the 
shoulder. 

After  amputation  of  the  shoulder-girdle  pneumonia  appears  to  be 
a  relatively  frequent  complication.  All  possibility  of  hypostatic  con- 
gestion should,  therefore,  be  guarded  against  by  raising  the  patient 
high  in  the  bed,  and  frequent  turning  from  side  to  side. 

The  Arm. — A  relatively  small  dressing  is  held  on  by  adhesive 
straps  and  bandage.  A  large  pad  is  placed  between  the  stump  and 
the  chest  and  a  swathe  band  holds  the  arm  against  the  chest  for  the  first 
five  or  six  days.  The  stitches  are  removed  on  the  tenth  day,  the  wound 
then  being  supported  by  adhesive  strips. 

Forearm. — The  arm  is  immobilized  for  ten  days  by  an  internal 
angular  splint  applied  with  the  forearm  intermediate  between  pronation 
and  supination.  The  splint  should  project  beyond  the  stump  for  i  or  2 
inches,  thus  furnishing  a  certain  amount  of  protection  for  it. 

Fingers. — The  hand  is  supported  by  an  anterior  splint  extending 
from  the  bend  of  the  elbow  to  just  beyond  the  finger-tips,  and  carried  in 
a  sling.     The  splint  is  taken  off  at  the  end  of  ten  days. 

Hip. — This  is  the  most  severe  of  all  amputations,^  and  measures 
to  combat  shock  form  a  very  important  part  of  the  after-treatment. 
Pressure  on  the  stump  is  avoided  by  a  small  firm  pillow  beneath  the 
ischial  tuberosity  on  the  amputated  side  and  a  cradle  over  the  pelvis. 
The  dressing  must  be  large  because  there  is  usually  free  drainage  of 
serum  from  the  wound.     It  is  held  in  place  by  plaster  straps,  outside 

^  Chavasse,  Lancet,  1900,  ii^  154. 


560  OPERATIONS    ON   THE  EXTREMITIES 

of  which  a  figure-of-8  bandage  is  apphed  about  the  pelvis.  The  dress- 
ing should  not  be  disturbed  for  at  least  four  days,  if  possible,  because 
of  the  additional  shock.  The  bowels  are  not  opened  for  this  length 
of  time  in  order  not  to  run  the  risk  of  soiling  the  dressing.  The  greatest 
of  care  must  be  observed  to  prevent  bed-sores. 

Thigh. — A  copious  dressing  is  used  because  here,  too,  the  discharge 
of  serum  is  considerable.  A  well-padded  posterior  splint  is  applied, 
extending  a  little  beyond  the  end  of  the  stump,  held  on  by  strips  of  ad- 
hesive plaster  and  a  spica  bandage.  The  distal  extremity  of  the  splint 
should  be  elevated  on  a  pillow  in  order  to  relax  the  quadriceps  extensor. 
The  splint  is  worn  for  ten  days. 

I^eg. — After  the  dressing  is  applied  the  knee  is  immobilized  and  the 
stump  supported  by  a  long  ham  splint,  which  is  held  on  by  plaster 
straps  and  a  bandage.  It  is  important  that  the  splint  extend  beyond 
the  end  of  the  stump,  so  as  to  furnish  protection  for  it.  This  sphnt  may 
be  removed  at  the  end  of  ten  days. 

Toes. — After  amputation  of  the  toes  rapid  union  of  the  wound  is 
promoted  if  a  long  plantar  splint  is  worn  for  ten  days,  but  this  is  not 
absolutely  necessary  if  the  patient  will  faithfully  use  crutches  and  keep 
the  foot  off  the  ground  for  this  length  of  time. 

References 

Petersen  and  Gocht:  Amputationen  u.  Exartik.  kiinstlichen  Glieder,  Stuttgart,  1907, 
with  complete  bibliography. 

Bier:  Ueber  Amputat.  u.  Exartik.,  Volkmann's  klin.  Vortrage,  1900,  No.  264,  1707. 
Bryant  and  Buck:  Amer.  Pract.  Surg.,  New  York,  1908,  iv,  263. 

LIGATION  OF  THE  INNOMINATE  ARTERY 

Aneurysm  of  the  innominate  artery  was  first  successfully  treated 
by  hgation  by  Burrell.^  Access  to  the  artery  is  gained  by  resection  of 
the  right  sternoclavicular  articulation  and  a  small  portion  of  both  the 
sternum  and  clavicle.  The  method  was  described  first  by  Cooper  in 
1859,^  but  was  not  used  again  until  Burrell,  at  the  time  unaware  of 
Cooper's  work,  performed  the  same  operation. 

The  muscles  overlying  the  artery  and  the  skin  are  sutured  without 
drainage,  and  a  dry  sterile  dressing,  held  in  place  by  plaster  strips,  is 
applied.  This  is  left  undisturbed  until  the  tenth  day,  when  the  stitches 
are  removed.  The  right  arm  is  wrapped  in  cotton  or  sheet-wadding 
and  bandaged  to  keep  up  its  heat.  In  Burrell's  case  the  pulsation  in 
the  right  radial  artery  returned  on  the  sixth  day.     To  insure  rest  for  the 

^  Boston  Med.  and  Surg.  Jour.,  1895,  cxxxiii,    125. 
^  Amer.  Jour.  Med.  Sci.,  1859,  xxxviii,  395. 


LIGATION    OF    THE    SUBCLAVIAN    ARTERY  561 

vascular  system  the  patient  is  kept  in  bed,  on  a  light  diet,  and  given 
morphin,  |  gr.,  every  four  hours.  The  latter  is  a  very  important  part 
of  the  after-treatment.  The  bowels  are  moved  on  the  fourth  day  and 
kept  free.  The  patient  is  allowed  out  of  bed  at  the  end  of  eight  weeks. 
There  is  some  swelling  and  more  or  less  loss  of  strength  in  the  arm  for  a 
time  after  the  operation. 

LIGATION  OF  THE  CAROTID  ARTERY 

Complications  and  Sequelae. — Cerebral  Symptoms. — These  are 
said  to  occur  in  as  many  as  25  per  cent,  of  cases,  and  may  appear  at  once 
or  not  until  some  days  after  operation.  All  such  symptoms  are  due 
to  the  diminished  cerebral  blood-supply,  and  vary  from  faintness,  giddi- 
ness, impaired  vision,  up  to  complete  hemiplegia  in  those  cases  where 
the  circle  of  Willis  is  congenitally  incomplete.^  The  after-treatment 
involves  no  special  detail  beyond  perfect  quiet  until  the  new  conditions 
are  well  established. 

Sepsis  is  always  possible,  and  where  this  occurs  and  silk  ligatures 
have  been  used,  the  sinus  will  probably  persist  at  least  three  weeks,  until 
the  silk  comes  away.  Wherever  notable  sepsis  takes  place,  the  danger 
of  secondary  hemorrhage  is  considerable. 

Recurrent  pulsation  frequently  appears,  but  nevertheless  the  cerebral 
pressure  is  undoubtedly  diminished  and  the  object  of  the  operation  thus 
accomplished. 

Lung  complications  are  said  to  be  not  uncommon,  due  to  the  dimin- 
ished freedom  of  respiratory  movements  secondary  to  the  disturbed 
,  circulation  in  the  brain  and  medulla. 

LIGATION  OF  THE  SUBCLAVIAN  ARTERY 
Complications  and  Sequelse. — The   mortality  in    this    opera- 
tion is  high  (out  of  48  cases,  25  die). 

Sepsis  is  the  greatest  danger.  If  it  occurs  outside  the  aneurysmal 
sac,  the  dangers  are,  of  course,  principally  from  secondary  hemorrhage. 
If  sepsis  occurs  within  the  sac,  the  liability  to  infection  seems  to  be  in- 
creased from  the  fact  that  the  ligature  is  so  close  to  the  sac  that  the  clot 
is  poorly  formed  and  loose,  and  embolism  is  liable  to  occur.  In  such 
cases  the  swelling,  which  has  first  diminished,  now,  in  the  second  or 
third  week,  begins  to  increase  in  size,  with  pain  and  tenderness,  but  with- 
out pulsation.  This  must  be  emptied  by  incision,  and  in  this  event 
secondary  hemorrhage  is  liable  to  take  place  and  can  be  met  only  by 

*  Walter  C.  Howe  (Boston  City  Hospital  Reports,  1903,  xiv,  162)  reports  such  a  case 
and  gives  complete  bibliography  of  the  subject. 
36 


562  OPERATIONS   ON   THE   EXTREMITIES 

attempts  at  packing.  Hemorrhage  at  any  time  after  operation  may  be 
looked  for,  even  though  asepsis  is  perfect,  because  of  the  diseased  con- 
dition of  the  artery  walls  which  lay  behind  the  original  lesion. 

Faulty  circulation  in  the  arm  causes  the  limb  to  become  numb,  cold, 
stiff,  and  weak.  After  the  wound  is  thoroughly  healed,  this  is  to  be  met 
by  the  application  of  warmth,  massage,  and  electricity. 

A  cord  of  the  brachial  plexus  may  he  included  in  the  ligature.  Such 
a  mistake  causes  an  agonizing  pain  at  the  site  of  operation  and  through- 
out the  length  of  the  arm.  It  must  be  immediately  relieved  by  further 
operation,  removing  the  ligature  and  placing  a  new  one  properly. 

The  pleura  may  he  injured  when  the  needle  is  passed  during  the 
operation,  but,  except  for  infection,  this  accident  is  of  little  importance. 

The  phrenic  nerve  or  the  subclavian  vein  may  rarely  be  injured  at 
the  time  of  operation,  but  these  are  rather  operative  details. 

LIGATION  OF  THE  EXTERNAL  ILIAC  OR  FEMORAL  ARTERY 

Complications  and  Sequelae. — Sepsis  and  secondary  hemorrhage 
from  sepsis  or  slipping  ligature  are  always  possibilities,  and  call  for  no 
new  directions  for  treatment. 

Gangrene  of  the  limb  should  be  uncommon  if  the  limb  is  well  pro- 
tected by  horizontal  position,  wrapping  in  cotton,  and  careful  use  of 
heaters. 

Pain  at  site  of  operation  may  be  persistent  as  the  result  of  the  tying- 
in  of  some  nerve-filament. 

Swelling  of  the  limb  is  to  be  met  by  wearing  a  flannel  or  elastic  ban- 
dage for  the  first  few  weeks. 

ARTERIAL  SUTURE 

The  first  suture  of  an  artery  was  performed  by  Hallowell,^  an  English 
surgeon,  in  1759.  The  method  which  he  employed  was  to  pass  a  pin 
through  the  lips  of  a  wound  in  the  brachial  artery  and  then  wind  a  thread 
about  it.  The  operation  was  successful.  Within  the  last  few  years  the 
brilliant  experimental  work  of  Carrel,"-^  Guthrie,  and  others  has  aroused 
renewed  interest  in  this  operation.  Among  others,  Lund  ^  and  Sher- 
man *  have  reported  successful  cases  of  arterial  suture.  The  number 
of  cases  is  still  limited,  but  from  the  study  of  the  available  literature  the 
following  rules  for  after-treatment  may  be  set  forth  as  conservative  and 

^  Lambert:   Medical  Observations  and  Inquiries,  London,  1762. 
^  Carrel:  Jour.  Amer.  Med.  Assoc,  1905,  xlv,  1645;  Ann.  Surg.,  1906,  xliii,  203;  Surg., 
Gyn.  and  Obst.,  1906,  ii,  266;  Bull.  Johns  Hopkins  Hosp.,  1907,  xviii,  i8. 
^  Ann.  Surg.,  1909,  xlix,  394. 
*  California  State  Medical  Journal,  1908,  vi,  56. 


MATAS'    OPERATION   FOR   ANEURYSM  563 

satisfactory,  to  be  later  modified  as  experience  with  this  operation 
increases. 

The  superficial  structures  are  united  with  catgut,  and  the  skin  with 
silkworm  gut  or  horsehair,  leaving  a  small  opening  into  the  tissues  about 
the  vessel  through  which  is  inserted  a  rubber  tissue  drain.  The  wound 
is  dressed  with  sterile  gauze  and  the  limb  immobilized  by  a  splint. 
The  drain  is  removed  after  twenty-four  hours.  The  stitches  are  taken 
out  on  the  tenth  day.  Immobilization  is  continued  up  to  three  weeks. 
In  the  upper  extremity  the  patient  may  go  about  carefully  after  ten  days, 
but  in  the  lower  he  should  be  kept  in  bed  three  weeks. 

Complications  and  Sequelae. — The  chief  complication  to  be 
feared  is  thrombosis,  which  may  result  in  obstruction  of  the  circulation  and 
occasionally  gangrene. 

Arteriovenous  Anastomosis. — This  operation,  employed  with 
some  success  by  Hubbard,^  for  gangrene  of  the  leg,  is  as  yet  on  the  surgi- 
cal frontier.     The  after-treatment  is  that  for  ligation  of  a  large  artery. 

MATAS'  OPERATION  FOR  ANEURYSM 

In  the  Matas  ^  operation,  either  with  or  without  obliteration  of  the 
lumen  of  the  artery,  the  aneurysmal  sac  is  occluded  by  a  deep  stitch  of 
silkworm  gut  or  catgut  on  either  side  of  the  wound,  passing  through  the 
skin  and  both  walls  of  the  sac,  and  tied  over  a  roll  of  gauze  to  maintain 
sufficient  tension  without  cutting  into  the  skin.  The  skin  is  then  sutured 
to  the  middle  of  the  bottom  of  the  sac  with  silkworm  gut  or  catgut,  the 
same  stitches  uniting  the  skin-edges.  The  furrow  thus  formed  is  filled 
with  sterile  gauze.  The  entire  limb  is  then  v/ound  with  cotton,  rein- 
forced over  the  line  of  the  artery.  Outside  of  this  several  strips  of  card- 
board are  placed,  covered,  in  turn,  by  more  cotton  or.  sheet-wadding, 
and  a  firm  gauze  bandage  applied  from  below  upward. 

When  the  seat  of  the  aneurysm  is  the  brachial  artery,  the  arm  is  held 
in  a  sling  and  a  circular  bandage  or  swathe  applied.  Where  the  femoral 
or  popliteal  artery  is  involved,  the  hmb  is  immobilized  by  a  posterior 
splint.  The  fingers  or  toes,  as  the  case  may  be,  should  be  left  exposed 
in  order  that  the  state  of  the  circulation  may  be  determined.  If  the 
extremity  remains  warm  and  the  color  good,  the  bandages  are  changed 
only  when  they  begin  to  loosen,  usually  in  about  forty-eight  hours,  but, 
in  the  absence  of  the  elevation  of  temperature,  the  gauze  over  the  wound 

^  Ann.  Surg.,  1906,  xliv,  559;    1908,    xlviii,  897. 

^  Matas,  Trans.  Amer.  Surg.  Assoc,  1902,  xx,  396.  See  also  F.  G.  Balch  and  F.  T. 
Murphy,  Aneurysm  of  the  External  Iliac  Artery,  Boston  Med.  and  Surg.  Jour.,  1909, 
clix,  860. 


564  OPERATIONS    ON   THE   EXTREMITIES 

is  left  undisturbed  until  the  tenth  day,  when  the  stitches  are  removed 
and  all  dressings  and  splints  omitted.  In  the  case  of  aneurysms  of  the 
lower  extremity  the  patient  should  not  begin  to  use  the  limb  for  three 
weeks,  and  in  those  of  the  upper  extremity  vigorous  movements  should 
be  avoided  for  some  time,  but  gentle  ones  may  be  attempted  after  the 
tenth  day. 

Complications  and  Sequelae. — Gangrene  may  result  from  the 
imperfect  establishment  of  collateral  circulation,  which  is  unavoidable; 
or  as  the  result  of  the  formation  of  a  clot  at  the  site  of  distal  compression, 
which  becomes  an  embolus  and  lodges  in  a  vessel  beyond  the  aneurysm. 
This  must  be  regarded  as  an  accidental  failure  of  technique.  From 
either  cause  gangrene  is  rare  and  requires  amputation. 

Secondary  hemorrhage  can  occur  only  as  a  result  of  imperfect  tech- 
nique and  demands  ligation  of  the  arterial  trunk. 

Suppuration  is  the  most  frequent  complication  and  probably  depends 
in  some  measure  on  failure  perfectly  to  obliterate  the  aneurysmal  cavity. 
It  is  manifested  by  elevation  of  temperature  and  severe  pain  at  the  site 
of  the  incision.     The  treatment  is  the  same  as  for  any  wound  infection. 

VARICOSE  VEINS  OF  LOWER  EXTREMITY 

After  the ,  commonly  employed  type  of  operation,  that  of  Mayo,^ 
using  his  vein  enucleator  and  making  three  to  five  or  more  incisions, 
there  remain  several  small  wounds  which  are  sutured  and  covered 
with  a  thin  layer  of  sterile  gauze  held  in  position  so  as  not  to  slip  by 
adhesive  strapping.  Collodion  is  not  so  good.  If  the  older  technique 
of  dissecting  out  the  venous  trunk  is  performed,  there  will  be,  instead, 
one  or  more  long  wounds,  which  have  to  be  carefully  sutured  and  which 
are  hard  to  keep  from  becoming  septic.  After  the  dry  sterile  dressing 
is  applied,  the  extremity  is  bandaged  from  toes  to  groin  with  a  3-inch 
"Ideal"  bandage. 

The  patient  is  kept  in  bed  with  the  leg  elevated  on  a  pillow  for  t^'elve 
days,  the  bandage  being  reapplied  daily,  but  the  wounds  left  undisturbed 
until  the  twelfth  day,  when  the  stitches  are  removed  and  the  dressing 
omitted.  The  patient  is  then  allowed  to  get  up,  but  continues  to  wear 
the  bandage  for  three  months. 

When  a  varicose  ulcer  has  been  excised  and  grafted,  a  roll  of  gauze 
is  placed  about  the  leg  above  and  below  the  area.  A  sheet  of  wire  gauze 
is  passed  about  this  portion  of  the  leg,  and  held  with  adhesive  plaster  in 
such  a  manner  that  it  is  supported  by  the  two  rolls  of  gauze  above 
referred  to  and  does  not  come  in  contact  with  the  grafted  area.     The 

^  C.  H.  Mayo,  Surg.,  Gyn.  and  Obst.,  1906,  ii,  3S5. 


SUTURE  OF  TENDON  AND  MUSCLE  565 

bandage  is  then  applied  over  this.  Thus  the  progress  of  the  graft  may 
be  watched  without  disturbing  it,  and  at  the  end  of  twelve  days  this 
dressing  is  removed  for  the  first  time,  and  a  simple  protective  dressing 
only  is  worn  over  the  grafted  area  from  this  time. 

Where  there  is  an  extensive  eczema  of  the  extremity  complicating 
varicose  veins  which  cannot  be  cleared  up  by  a  careful  preliminary  treat- 
ment before  operation,  this  area  should  be  sealed  over  with  compound 
tincture  of  benzoin  until  the  operative  w^ound  is  sufficiently  well  healed, 
two  or  three  days,  to  prevent  the  entrance  of  infection. 

Complications  and  Sequelae. — Infection  and  pulmonary  em- 
bolism occur  in  rare  instances. 

SUTURE  OF  TENDON  AND  MUSCLE 

Wounds  of  tendons  are  most  common  at  the  wrist.  Instances  of 
ruptures  of  the  long  head  of  the  biceps,  the  c{uadriceps  extensor,  and 
other  muscles  and  tendons  have  been  reported.  If  an  important  tendon 
is  divided,  in  part  or  completely,  the  wound  is  thoroughly  cleaned,  the 
tendons  sutured  with  fine  silk  or  Pagenstecher,  and  the  wound  closed 
with  silk  or  silkworm  gut.  If  the  w^ound  is  much  lacerated  or  there  is 
particular  reason  to  fear  infection,  a  very  small  rubber  tissue  or  catgut 
drain  may  be  inserted  just  under  the  skin,  to  be  taken  out  after  forty- 
eight  hours. 

The  dressing  should  be  voluminous  enough  to  absorb  all  the  oozing. 

O  «wJ  o 

A  splint  must  be  so  designed  and  applied  that  the  part  is  so  flexed  or 
hyperextended,  as  the  case  may  require,  that  no  tension  is  allowed  to  fall 
on  the  uniting  tendons.  A  splint,  anterior  or  posterior,  is  applied  to  the 
opposite  aspect  of  the  limb  from  that  of  the  wound,  long  enough  to  fixate 
all  the  joints  between  the  points  of  origin  and  insertion  of  the  muscles 
involved.  If  made  of  wire,  it  can  readily  be  bent  to  the  proper  angle, 
otherwise  it  is  built  up  or  padded  at  the  distal  end  in  order  that  the 
flexion  or  hyperextension  may  be  efficiently  maintained.  The  forearm 
and  splint  are  then  bandaged  and  the  arm  carried  in  a  sling. 

The  wound  is  inspected  without  removing  the  splint  if  possible, 
at  the  end  of  forty-eight  hours,  and  again  on  the  fourth  day.  On  the 
seventh  day  the  stitches  are  removed. 

The  time  for  removing  the  splint  and  beginning  motion  cannot 
be  arbitrarily  stated.  The  purpose  of  after-treatment  is  to  prevent  too 
firm  adhesions  of  the  united  tendon  in  its  sheath,  and,  at  the  same 
time,  to  avoid  undue  strain  on  the  new  union.  The  arm  is  kept  on  the 
splint  for  four  weeks,  but  after  the  second  week  the  splint  should  be 
removed  twice  a  week  and  careful  passive  motion  of  the  fingers  carried 


566  OPERATIONS    ON   THE   EXTREMITIES 

out,  great  pains  being  taken  not  to  flex  or  extend  them  to  an  extent  to 
strain  the  sutured  place. 

At  the  end  of  four  weeks  the  sphnt  is  omitted  and  careful  use  of  the 
forearm  begun.  Massage  and  passive  motion  should  be  carried  out 
until  the  stiffness  disappears.  Wounds  of  the  tendons  at  the  wrist  are 
frequently  complicated  by  injury  to  the  median  nerve,  which  should  be 
repaired  at  the  same  time,  and  treated  by  electricity  after  removal  of 
the  splint. 

After  woimds  of  the  larger  tendons,  such  as  the  biceps  or  quadriceps 
extensor,  have  been  sutured,  the  limbs  are  best  immobilized  by  plaster- 
of-Paris.  In  wounds  of  the  biceps  tendon  the  arm  should  be  maintained 
in  acute  flexion  for  six  weeks,  after  which  careful  use  may  be  begun. 
After  suture  of  the  quadriceps  extensor  the  limb  should  be  immobilized 
in  extension  by  a  plaster  spica  extending  from  the  crests  of  the  ilia  to 
the  ankle.  This  is  worn  for  eight  weeks,  after  which  passive  motion  is 
begun,  but  no  active  use  of  the  leg  is  allowable  for  three  months. 

TENDON  TRANSPLANTATION 

The  general  after-care  for  tendon  transplantation,^  whether  the 
healthy  tendon  be  sewed  into  the  paralytic  tendon  or  directly  into  the 
periosteum,  involves  no  principle  different  from  that  of  tendon  suture. 
Bearing  in  mind  the  poor  blood-supply  of  the  tendons,  the  same  con- 
servatism is  exhibited  before  subjecting  the  sutured  region  to  great 
strain.  A  split  plaster  cast  should  be  worn  for  six  or  eight  weeks,  and 
then,  on  a  leg,  a  properly  constructed  brace  should  be  applied.  Massage 
and  passive  motion  should  be  carried  out  assiduously  by  an  expert. 

NERVE  SUTURE 

The  nerves  most  commonly  injured  and  treated  by  suture  are  the 
musculospiral  in  fractures  of  the  humerus,  the  median  at  the  wrist,  and 
the  ulnar  near  the  internal  condyle.  The  skin  incision  is  closed  without 
drainage  unless  the  injury  was  accompanied  by  considerable  trauma 
to  the  soft  parts,  and  covered  with  a  small,  dry,  sterile  dressing,  and 
the  arm  immobilized  in  such  a  position  that  the  nerve  will  be  under  no 
tension.  In  suture  of  the  musculospiral  and  of  the  ulnar  this  is  secured 
by  a  straight  internal  splint  extending  from  the  axilla  to  the  finger-tips, 
maintaining  the  arm  in  the  position  of  complete  extension.  After 
suture  of  the  median  nerve,  which  is  nearly  always  accompanied  by 
suture  of  one  or  more  of  the  tendons  at  the  wrist,  unless  the  tendon 
suture  has  been  done  previously  and  the  nerve  injury  overlooked,  a 

^  E.  H.  Bradford  and  R.  Soutter,  Boston  Med.  and  Surg.  Jour.,  1907,  clvi,  655. 


NERVE   ANASTOMOSIS  567 

posterior  splint  is  applied  reaching  from  the  elbow  to  beyond  the  finger- 
tips and  bent  up  or  padded  at  the  distal  extremity  to  maintain  flexion 
at  the  carpus. 

In  the  absence  of  tendon  injury  immobilization  is  maintained  for 
two  weeks,  after  which  massage  and  electricity  are  commenced  and  the 
patient  gradually  allowed  to  resume  the  use  of  his  arm.  Electricity 
should  be  given  daily  for  fifteen  minutes,  begirming  with  the  galvanic 
current  applied  to  the  muscles  supplied  by  the  sutured  nerve.  As  soon 
as  the  muscles  begin  to  react  to  stimulation  of  the  nerve  above  the 
point  of  suture  the  electrode  should  be  applied  to  the  nerve  itself.  As 
soon  as  regeneration  is  sufficiently  advanced  to  produce  reaction  to  the 
faradic  current,  this  may  be  employed.  Massage  three  times  a  week 
will  aid  in  maintaining  the  nutrition  of  the  paralyzed  muscles.  The 
maximum  improvement  after  nerve  suture  may  not  be  reached  for  one 
year,  hence  treatment  must  be  faithfully  continued  for  this  length  of 
time. 

SUTURE  OF  THE  BRACHIAL  PLEXUS 

The  wound  is  closed  except  for  a  small  drain  at  its  dependent  portion, 
if  necessary,  and  a  plaster  bandage  is  applied  in  such  a  way  as  to 
elevate  the  shoulder,  rotate  the  chin,  and  incline  the  head  toward  the 
affected  side.  The  wound  may  be  dressed  through  a  window  cut  in 
the  plaster  over  it,  the  wick  being  removed  on  the  second  day  and 
omitted.  A  dry  sterile  dressing  is  applied  until  the  wound  is  united. 
The  stitches  are  removed  on  the  seventh  day.  Immobilization  is  main- 
tained for  three  weeks,  after  which  the  plaster  is  removed  and  electricity, 
massage,  and  passive  motion  of  the  arm  carried  out  daily  after  the  same 
principles  which  apply  to  the  after-treatment  of  suture  of  smaller  nerve- 
trunks.     Improvement  is  slow  and  may  progress  during  several  years. 

NERVE  ANASTOMOSIS 

The  first  successful  nerve  anastomosis  in  man  was  reported  by  Sick 
and  Sanger  in  1897.^  The  distal  stump  of  a  paralyzed  musculospiral 
nerve  was  grafted  into  the  median,  and  the  patient  regained  perfect 
control  of  the  muscles  supplied  by  both  nerves.  Anastomosis  of  the 
spinal  accessory  and  facial  was  performed  in  1895  by  Ballance,^  and 
by  Faure  "^  in  1898.  Both  operations  were  failures.  The  first  success- 
ful anastomosis  of  these  two  nerves  was  done  by  Kennedy  in  1899.*    In 

^  Arch.  f.  klin.  Chir.,  1897,  liv,  271. 

^  Brit.  Med.  Jour.,  1903,  i,  1009. 

^  Gaz.  des  Hop.,  1898,  71^  annee,  259. 

*  Phil.  Trans.  Roy.  Soc,  1900,  cxciv,  127. 


568  OPERATIONS    ON   THE   EXTREMITIES 

Kennedy's  case  the  operation  was  performed  for  facial  tic,  and  anasto- 
mosis followed  immediately  the  interruption  of  function  of  the  facial 
nerve.  Anastomosis  of  the  hypoglossal  with  the  facial  was  likewise 
first  performed  by  Ballance  (loc.  cit.)  in  1903.  Since  the  work  of  these 
pioneers  the  operations  of  facial  anastomosis  have  been  performed 
by  a  considerable  number  of  surgeons,  particularly  for  nerve  injury 
during  mastoid  exenteration.  The  results  have  been,  on  the  whole, 
promising.  Mintz  ^  found  in  22  published  cases  only  7  which  were 
absolute  failures.  In  infantile  paralysis  nerve  anastomosis  was  first 
performed  by  Peckham,^  who  grafted  certain  branches  of  the  internal 
popliteal  into  the  paralyzed  external  popliteal  nerve. 

The  after-treatment  of  nerve  anastomosis  does  not  differ  from  that 
of  simple  nerve  suture  as  regards  electricit}',  massage,  immobilization, 
etc.  After  operations  upon  the  facial  nerve  the  skin  incision  is  closed 
with  an  intracuticular  suture  of  silkworm  gut  and  covered  with  a  sterile 
cocoon,  which  is  removed  at  the  end  of  ten  days  and  the  stitch  taken 
out.  No  immobilization  of  the  head  is  required.  Electricity  is  begun 
at  the  end  of  ten  days. 

After  anastomosis  of  the  internal  with  the  external  popliteal  the 
incision  is  closed  without  drainage  and  the  limb  immobilized  for  two 
weeks  in  plaster.  At  the  end  of  this  time  the  plaster  is  taken  off,  the 
stitches  removed,  and  massage  and  electricity  commenced. 

Complications  and  Sequelae. — The  complications  of  facial 
anastomosis  are  paralysis  of  the  muscles  supplied  by  the  sound  nerve, 
resulting  in  paralysis  and  hemiatrophy  of  the  tongue  vrhen  the  hypo- 
glossal is  used,  or  paralysis  of  the  sternomastoid  and  trapezius  if  the 
spinal  accessory  is  selected,  accompanied  by  a  tendency  to  contraction 
on  the  part  of  corresponding  muscles  on  the  opposite  side;  and  associ- 
ated movements  of  the  groups  of  muscles  supplied  by  both  nerves.  The 
second  of  these  results  in  more  or  less  severe  spasm  of  the  muscles  of 
the  face  with  attempts  to  move  the  shoulder  or  tongue  as  the  case  may 
be. 

Atrophy  and  paralysis  may  be,  to  a  considerable  extent,  obviated 
by  not  completely  di\iding  the  sound  nerve,  but  merely  taking  part  of 
it  to  form  the  anastomosis,  or  anastomosing  the  distal  end  of  the  para- 
lyzed nerve  directly  into  the  sound  one.  Even  under  such  circumstances 
more  or  less  atrophy  and  paralysis  will  result,  but  this  will  entirely  cleai 
up  within  two  or  three  months.  Electricity  should  be  applied  to  the 
muscles  normally  supplied  by  the  sound  as  well  as  those  by  the  paralyzed 

^  Cent.  f.  Chir.,  1904,  xxxi,  6S4. 
^  ProA-idence  Med.  Jour.,  1900,  i,  i. 


PSOAS   ABSCESS  569 

nerve.  Improvement  in  the  appearance  of  the  face  during  repose  is 
the  first  sign  of  returning  function  in  the  facial  nerve.  This  may  be 
expected  within  a  few  weeks,  but  even  the  shghtest  power  of  motion  is 
not  to  be  looked  for  sooner  than  three  to  five  months  or  even  longer. 
The  maximum  improvement  may  not  be  reached  for  over  a  year. 

Associated  movements  of  the  facial  muscles  with  the  trapezius  muscle 
or  the  tongue,  depending  on  whether  the  spinal  accessory  or  the  hypo- 
glossal nerve  is  employed,  are  usually  present,  but  may  be  greatly  dimin- 
ished by  reeducation  and  exercises. 

PSOAS  ABSCESS 

Whether  a  psoas  abscess  ruptures  and,  therefore,  makes  its  own 
vent,  or  is  opened  by  primary  operation,  the  after-treatment  is  the 
same. 

If  the  site  of  the  original  disease  is  in  the  spine  proper,  it  is  assumed 
that  the  back  has  been  fixed  with  relative  lordosis  in  a  plaster  jacket.^ 
If  the  disease  is  in  the  sacro-iliac  joint,  for  fixation  of  the  pelvis  a  tight- 
fitting  girdle  may  be  employed  if  it  gives  subjective  relief.  Proper 
care  of  the  sinus  and  its  discharge  consists  only  in  cleanliness.  The 
skin  about  the  mouth  of  the  sinus  is  cleaned  once,  twice,  or  oftener 
daily,  according  to  the  amount  of  discharge;  it  is  then  gone  over  with 
70  per  cent,  alcohol;  some  emollient  skin  protective,  such  as  zinc  oint- 
ment, is  spread  about,  and  a  probe  wrapped  in  cotton  -saturated  with 
tincture  of  iodin  is  run  deep  into  the  sinus  once  daily.  If  practicable, 
the  region  is  exposed  to  direct  sunlight. 

Everything  possible  for  general  hygiene  should  be  done,  t^venty- 
four  hours  a  day  out-of-doors  being  one  of  the  most  important 
requisites. 

Complications  and  Sequelae. — Obstruction  to  the  Drainage. — 
The  reappearance  of  local  pain  and  tenderness,  with  fever,  particularly 
if  the  amount  of  discharge  is  at  the  same  time  markedly  diminished, 
should  suggest  that  the  sinus  no  longer  efficiently  drains  the  cavity. 
A  flexible  uterine  sound  may  be  inserted  gently  and  manipulated  until 
a  thorough  opening  is  assured. 

Distant  or  General  Tuberculosis. — It  should  always  be  in  mind  that 
the  disease  may  be  manifest" at  the  same  time  in  lungs  or  kidneys  or 
other  parts,  depending  much  upon  one's  particular  resistance  to  this 
infection.     The  wise  use  of  tuberculin  should  be  considered. 

Neuralgia. — Rarely,  in  a  healing  sinus  which  points  in  the  groin 
the  contraction  of  scar  tissue  may  involve  the  anterior  crural  or  other 

^  E.  G.  Bracket!  and  L.  R.  G.  Crandon,  Boston  Med.  and  Surg.  Jour.,  1905,  cliii,  515. 


570  OPERATIONS    OX   THE   EXTREMITIES 

nerves  with  paresis  of  tiie  quadriceps  extensor  and  much  neuralgic  pain. 
Time  and  galvanism  may  give  rehef,  othenvise  it  will  become  necessary 
to  free  the  nerve  of  pressure  by  operation. 

INGUINAL  BUBO  (ABSCESS   OF   THE  GROIN) 

The  vertical  incision  is  by  far  the  best,  in  that  it  drains  most  effici- 
ently and  heals  without  the  edges  dimpling  in,  as  they  do  in  the  parallel 
to  groin  incision.  Iodoform  gauze  or  paste  packing  for  the  first  tiventy- 
four  hours  is  used  for  ambulatory  cases.  If  the  patient  can  remain 
recumbent,  the  salt  and  citrate  poultice  most  favors  drainage.  As 
healing  proceeds  the  oleoresin  of  copaiba  or  balsam  of  Peru  may  be 
used.  To  stimulate  indolent  granulation  tincture  of  iodin  in  the  depths 
of  the  wound  is  the  best  apphcation.  Superabundant  granulations 
should  be  cut  down  with  scissors  curved  on  the  flat. 

The  origin  of  the  enlarged  lymph-node  should  be  sought  on  genitals 
or  lower  extremity  and  treated. 

PARONYCHIA  AND  PERIONYCHIA 

If  the  septic  process  involves  the  sulcus  from  which  the  nail  arises, 
it  tends  to  become  chronic,  with  deformity  of  the  nail  unless  early  in  the 
disease  the  nail  is  removed.  Mere  incision,  as  a  rule,  is  not  sufficient. 
If  the  nail  is  removed,  no  incision  is  necessary.  After  removal  a  rubber 
ffiiger-cot  with  a  few  drops  of  glycerin  in  the  distal  end  of  it  is  slipped 
over  the  finger,  and  under  these  conditions  it  is  allowed  to  macerate, 
with  an  occasional  cleaning,  for  tw^o  or  three  days.  At  the  end  of  this 
time  all  dressing  is  removed  except  a  bit  of  balsam  of  Peru  or  scarlet 
red  ointment  imtil  the  epithelium  is  formed  over  the  bed  of  the  nail. 
The  new  nail  will  grow  in  from  four  to  six  months. 

INGROWING  TOE-NAIL 

Whatever  the  type  of  operation,  one  expects  a  mildly  septic  wound. 
Salt  and  citrate  soaks  and  poultices  are  to  be  used  until  the  active  in- 
flammation has  subsided.  Emollient  dressings  are  used  during  the 
healing. 

Proper  shoeing  should  be  prescribed.     (See  p.  315.) 

PALMAR  GANGLION;  TUBERCULOUS  TENOSYNOVITIS 
If  primary  union  takes  place  after  the  excision  of  the  melon-seed 
sac,  the  most  important  part  of   after-treatment  consists  in   contin- 
uous efforts  to  prevent  the  matting  together  of  the  denuded  tendons. 
This  calls  for  active  and  passive  motion  of  the  fingers  to  their  limits. 


dupuytren's  contraction  571 

Should  a  wound  not  heal  by  primary  union,  it  should  be  treated  as  any 
open  tuberculous  wound;  namely,  by  daily  application  of  tincture  of 
iodin  and  exposure  to  sunlight. 

DUPUYTREN'S  CONTRACTION 

Practically  the  only  operative  procedure  now  carried  out  in  these 
cases  of  contraction  of  the  palmar  fascia  is  the  so-called  open  method, 
by  which  the  fascia  is  dissected  out.  This  is  to  be  preferred  over  the  older 
methods  of  subcutaneous  fasciotomy  and  the  V  incision  of  Busch, 
through  skin  and  fascia,  sewed  up  as  a  Y,  because  of — ^(i)  the  lessened 
liability  to  recurrence;  (2)  the  lessened  danger  of  injuring  nerves  and 
vessels;  and  (3)  the  short  after-treatment,  without  the  necessity  of 
wearing  expensive  mechanical  appliances.  The  dissection  can  be 
carried  out  through  a  longitudinal  incision  over  each  contraction  band 
(Kocher),  or,  better  still,  in  case  two  or  more  fingers  are  affected,  a  U- 
shaped  flap  can  be  turned  back  onto  the  wrist  (Keen),  uncovering  the 
entire  palm.  The  hand  can  be  put  up  in  plaster-of -Paris  or  on  a 
simple  malleable  iron  splint,  or  on  a  palmar  splint  of  wood. 

The  importance  of  complete  asepsis  is  to  be  emphasized.  The 
hand  should  be  thoroughly  cleaned  before  the  operation  (Chap.  XXXIX, 
p.  357),  and  it  should  be  protected  with  care  until  entirely  healed. 
Sepsis  in  the  wound  usually  means  permanent  loss  of  function  through 
interference  with  the  tendons.  Ligatures  should  be  avoided  so  far  as 
possible. 

Sometimes  not  only  the  palmar  fascia  and  its  prolongations  into 
the  fingers  must  be  excised,  but  the  resulting  contraction  of  the  flexor 
tendons  in  old  cases  miust  also  be  corrected  by  splitting  and  hemisection. 
The  hand  should  be  made  to  straighten  freely.  It  should  be  held 
straight  and  a  few  sutures  of  horsehair  put  in  to  approximate  the  skin- 
edges.  A  sterile  dressing  should  be  applied  and  the  hand  and  finger 
bandaged  to  a  palmar  splint  or  to  a  malleable  iron  strap,  which  should 
extend  from  the  wrist  to  the  tips  of  the  affected  fingers.  This  should 
be  left  on  six  days,  by  which  time  the  skin  will  be  fairly  well  healed. 
Gentle  passive  movements  should  now  be  given  the  fingers  and  the 
wound  redressed.  Stitches  should  be  out  on  the  eighth  or  tenth  day, 
and  if  at  the  time  of  operation  the  hand  was  put  up  slightly  flexed, 
it  should  be  fully  extended  by  this  time.  After  the  stitches  are  out 
a  collodion  dressing  should  be  applied,  to  be  kept  on  until  the  healing 
is  absolute  and  massage  and  passive  movements  regularly  instituted. 
On  returning  to  work  the  patient  should  wear  a  leather  protector  in 
the  palm. 


572  OPERATIONS   ON   THE   EXTREMITIES 

If  the  contraction  has  been  severe,  the  fingers  had  better  not  be 
put  up  straight  immediately  after  the  operation  on  account  of  the  pain 
from  stretching  the  digital  nerves,  which  have  been  structurally  short- 
ened. In  extensive  dissections,  also,  a  slight  degree  of  flexion  is  usually 
recommended  until  circulation  is  adjusted.^ 

Calot  ^  is  more  radical,  and  holds  the  hand  in  complete  extension 
or  even  hyperextension,  then  inserts  the  sutures  and  puts  on  a  plaster- 
of-Paris  mitt,  the  end  of  which  is  trimmed  off  so  as  to  uncover  the  pulps 
of  the  finger-tips  and  allow  the  circulation  and  innervation  of  the  fingers 
to  be  closely  observed.  The  day  after  operation  this  is  bivalved  in 
order  to  relieve  internal  tension.  It  is  kept  on  three  weeks,  and  then 
removed  and  the  fingers  manipulated. 

SKIN-GRAFTS  3 

Thiersch  Grafts. — A  convenient  and  efficient  form  of  dressing 
is  sterilized  silver-foil,  after  the  manner  first  ad^^sed  in  America  by 
Halsted  at  the  Johns  Hopkins  Hospital.  Virgin  silver-foil  comes  in 
books,  each  leaf  separated  from  the  next  by  a  sheet  of  tissue.  One 
or  more  books  are  put  between  two  blocks  of  wood  and  the  whole  steril- 
ized by  baking.  The  silver  book,  having  the  folded  edge  cut  off,  now 
becomes  a  pile  of  alternate  foil  and  paper  tissue.  After  the  grafts  are 
placed  they  are  fairly  well  dried  by  very  gentle  sponging.  A  layer  of 
tissue  with  foil  on  top  is  now  reversed  over  the  grafted  area  and  the  paper 
withdrawn,  leaving  a  layer  of  silver  which  shortly  breaks  up  into  granu- 
lated particles.  One  method  is  to  cut  the  original  sheet  into  strips 
and  apply,  leaving  the  paper  well  wet,  in  clap-board  layers,  next  the 
silver.  Better,  in  my  experience,  is  it  to  remove  the  paper.  When 
the  whole  area  is  well  covered  with  silver,  loosely  packed  sterile  gauze 
of  considerable  thickness,  so  as  to  absorb  the  ooze,  is  placed  OA^er  it 
and  a  dressing  which  will  not  confine  the  discharges  applied.  If  the 
part  grafted  is  a  limb,  it  should  be  fixed  in  a  splint.  As  a  rule,  no  further 
dressing  need  be  done  for  seven  days.  At  that  time  the  gauze  next 
the  silver  should  be  teased  off,  wetting  at  the  same  time  with  sterile 
saline  solution,  taking  time  and  care  to  remove  it.  Dry  dressings  for 
a  few  more  days  should  result  in  complete  healing.  Uncovered  areas 
will  need  regrafting  later. 

Thiersch  grafts  may  be  dressed  from  the  first  by  clap-board  layers 

^  A.  H.  Tubby,  Trans.  Amer.  Orthop.  Assoc,  1900,  xiii,  149,  and  Lancet,  1901,  i,  90. 
^  L'Orthopedie  Indispensable,  1909,  705. 

3  For  a  recent  consideration  of  this  subject  see  Ehrenfried  and  Cotton,  "Reverdin  and 
Other  Methods  of  Skin-graft,"  Boston  Med.  and  Surg.  Jour,  1909,  clxi,  911. 


SKIN-GRAFTS  573 

of  sterile  cotton  cloth  in  ^-inch  strips  containing  holes  here  and  there 
for  the  escape  of  serum.  A  dry  dressing  is  applied  outside  of  these 
strips.^ 

Reverdin  Grafts. — These  grafts  are  removed  from  a  clean  area  of 
skin  with  a  needle  and  a  knife.  The  process  does  not  hurt  enough 
usually  to  make  cocain  necessary.  Such  a  point  of  skin  is  then  laid 
here  and  there  all  over  the  clean  granulating  area  to  be  grafted.  Silver 
foil  or  sterile  fenestrated  compress  cloth  may  be  used  in  these  dressings. 

"Wolf  Grafts. — These  grafts  include  the  whole  thickness  of  the 
skin  into  the  subcutaneous  tissue,  and  will  take  very  well  on  face  and 
neck;  less  well  elsewhere.  Dry  dressing  should  be  used,  the  greatest 
care  being  taken  that  there  is  enough  pressure  to  hold  the  graft  against 
the  area  upon  which  it  is  planted,  but  not  enough  pressure  to  discourage 
circulation  into  it. 

^  Brockway,  Johns  Hopkins  Hosp.  Bull.,  1889,  i,  36. 


CHAPTER  LI 

OPERATIONS  ON  BONES  AND  JOINTS 
EXCISION  OF  ELBOW 

Passive  motions  of  the  fingers  and  wrist  should  begin  on  the  second 
or  third  day.  The  new  fiail-joint  at  the  elbow  should  be  moved  pas- 
sively as  early  as  the  eighth  or  tenth  day.  This  may  be  done  by  putting 
the  joint  up  after  the  operation  on  an  internal  angula.r  splint,  provided 
at  its  angle  with  a  turn-buckle.  Twisting  this  turn-buckle  will  give  a 
gradually  regulated  and  safe  movement.  If  the  operation  has  been 
for  tuberculosis,  persistent  remains  of  the  disease  or  sinuses  may 
modify  the  treatment,  but  if  the  excision  has  been  for  traumatic  anky- 
losis, constantly  increasing  passive  motion  should  be  practised  after 
the  tenth  day  and  active  motion  tried  in  three  weeks. 

Ability  to  use  the  new  joint  depends  much  on  the  character  of  the 
patient,  his  courage,  and  previously  acquired  mechanical  dexterity. 
The  patient  should  be  given  a  weight  to  carry,  such  as  a  pail  each  day 
containing  more  water.  In  the  case  of  a  child,  the  sound  arm  may 
be  bound  up  so  that  the  excised  joint  must  be  used. 

The  operation  is,  indeed,  but  a  small  part  of  the  treatment.  Rota- 
tion of  the  forearm  will  be  lost,  and  mere  rotation  of  the  whole  limb 
at  the  shoulder  substituted  unless  early  care  is  taken  to  preserve  fore- 
arm rotation.  At  first  the  upper  end  of  the  forearm  should  be  firmly 
held  by  one  hand  and  the  patient's  hand  rotated  passively  with  the 
nurse's  other  hand.  At  the  end  of  four  months  motion  in  the  new 
joint  should  be  free  and  fairly  efl&cient,  but  the  final  perfection  of  the 
joint  may  not  be  attained  short  of  a  year. 

Excision  of  the  joint  for  tuberculosis  is  now  rarely  practised,  treat- 
ment for  this  condition  having  reduced  itself  to  the  use  of  fixation,  or 
passive  congestion,  or  vaccines,  or  all  of  these  methods.  When  the 
tuberculosis  has  subsided  and  has  been  quiet  three  or  four  years,  then 
excision  may  be  practised  as  if  the  condition  were  merely  traumatic, 
and  the  after-treatment  is,  of  course,  the  same. 

EXCISION  OF  SHOULDER- JOINT 

In  general,  the  same  comments  should  be  made  concerning  the 
after-care  in  this  operation  as  in  the  case  of  the  elbow.     Passive  move- 

574 


EXCISION   OF   JOINTS  575 

ment  should  not  be  begun  until  the  deep  parts  of  the  wound  are  suf- 
ficiently healed;  that  is  to  say,  ten  to  fourteen  days.  Then  passive 
motion  is  followed  by  increasing,  graded,  active  motion.  A  large  enough 
pad  must  be  maintained  in  the  axilla  to  prevent  the  new  head  of  the 
bone  being  pulled  in  against  the  coracoid  process,  and  to  hold  it  instead 
in  the  glenoid  cavity.  The  normal  motions  of  the  humerus,  in  rela- 
tion to  the  scapula,  should  be  recalled  and  resumed,  in  order  that  none 
should  be  lost.  The  motions,  such  as  sweeping,  rotating  the  crank  of 
a  clothes-wringer,  bringing  a  gun  into  proper  position  at  the  shoulder, 
may  all  be  practised. 

EXCISION  OF  WRIST 

Passive  motion  of  the  fingers  should  be  begun  on  the  second  day, 
the  wrist  or  seat  of  operation,  however,  being  thoroughly  supported 
and  fixed  by  splint  and  dressing.  If  motion  of  the  fingers  is  not  begun 
early,  the  tendons  become  adherent  and  the  hand  is  useless.  As  the 
parts  get  stronger  the  splint  is  made  shorter,  though  some  support  should 
be  worn  until  there  is  no  tendency  for  the  new  joint  to  collapse  in  any 
direction — in  short,  until  it  is  strong.  Some  kind  of  leather  support, 
molded  to  fit  the  limb  from  the  middle  of  the  forearm  to  the  knuckles, 
should  be  devised. 

EXCISION  OF  HIP 

The  wound  is  closed  except  for  a  space  at  the  lower  angle,  where 
a  provisional  stitch  is  inserted  and  a  cigarette  drain  passed.  At  the 
end  of  forty-eight  hours  the  drain  is  removed  and  the  stitch  tied.  Gold- 
thwait.  Painter,  and  Osgood  ^  insist  upon  the  importance  of  this  early 
closure  of  the  wound.  The  patient  is  kept  in  bed  six  weeks,  with  ex- 
tension to  the  limb.  At  the  end  of  this  time  a  plaster  spica  is  applied 
with  the  thigh  in  abduction  and  slight  outward  rotation,  and  the  patient 
is  got  up  on  a  high  sole  and  crutches.  Weight  bearing  should  not  be 
attempted  for  ten  to  twelve  months,  although  the  spica  need  not  be 
worn  more  than  three  or  four  months  unless  there  is  great  instability 
of  the  remaining  joint. 

EXCISION  OF  KNEE 

The  result  of  this  operation  is  a  stiff  knee.  No  sutures  are  neces- 
sary in  the  bones.  The  wound  is  closed  with  a  small  drain  which  is 
removed  at  the  end  of  forty-eight  hours,  and  a  previously  inserted  pro- 
visional stitch  tied.  The  limb  is  immobilized  in  a  plaster  reaching 
from  the  perineum  to  the  toes.      Goldthwait,  Painter,   and  Osgood  ^ 

^  Diseases  of  the  Bones  and  Joints,  Boston,  1909,  242. 
^  Op.  cit.,  p.  243. 


576  OPERATIONS   ON   BONES   AND   JOINTS 

recommend  that  the  leg  should  be  put  up  with  5  degrees  of  flexion  at 
the  knee-joint  rather  than  in  complete  extension,  as  this  will  give  a  less 
awkward  leg.  At  the  end  of  three  weeks  the  patient  is  gotten  out  of 
bed,  and  in  two  w^eeks  more  locomotion  with  the  aid  of  crutches  and  a 
high  sole  on  the  shoe  of  the  opposite  foot  is  begun.  At  the  end  of 
eight  weeks  the  plaster  is  taken  off  and  the  union  tested.  If  firm, 
weight  bearing  may  be  begun  at  ten  wrecks.  The  plaster  should  be 
reapplied  and  worn  until  the  end  of  twelve  weeks. 

OPEN  (OR  "COMPOUND")  FRACTURES 

After  the  operation  the  limb  should  be  put  up  in  permanent  appa- 
ratus adapted  to  the  site  and  nature  of  the  fracture,  except  where  the 
trauma  was  attended  by  much  mangling  of  the  tissues,  with  the  con- 
sequent increased  possibility  of  direct  infection.  In  this  case  the  ap- 
paratus should  be  designed  to  facilitate  the  necessary  change  of  dressings 
while  yet  maintaining  the  fragments  with  sufficient  firmness  to  avoid 
pain  or  excessive  deformity.  During  the  first  week  attention  should  be 
focused  on  the  wound  rather  than  the  fracture. 

Ordinarily,  under  our  present-day  conservative  treatment,  unneces- 
sary manipulation  of  the  wound  is  severely  avoided.  The  skin  and  such 
torn  tissue  as  presents  through  the  wound  is  cleaned  scrupulously,  as 
little  trimming  as  possible  is  done,  and  then  the  parts  are  restored 
as  nearly  as  may  be  to  their  normal  relations,  without  further  devitaliz- 
ing the  bruised  tissues  by  handling  or  strong  antiseptic  irrigation.  If 
the  skin  wound  is  not  large,  it  is  left  open  for  drainage  of  exudate,  which 
is  sure  to  follow.  It  may  be  enlarged.  If  the  fracture  is  deep,  a  drainage 
tract  may  be  maintained  by  a  coiled  piece  of  rubber  dam  or  a  small 
soft  tube.  Unnecessary  sutures  are  a  distinct  evil  and  deep  sutures 
are  rarely  indicated.  If  catgut  is  used  for  the  skin,  the  stitches  may 
be  left  to  take  care  of  themselves,  if  no  infection  follows  and  there  is  no 
drainage  to  remove,  until  such  time  as  the  dressing  or  plaster-of-Paris 
is  removed  for  the  purpose  of  inspecting  position. 

There  is  a  large  series  of  open  fractures  which,  after  operation, 
should  receive  as  good  fixation  as  though  there  was  no  external  wound; 
for  instance,  an  open  fracture  in  the  middle  of  the  leg  or  forearm  is 
preferably  put  up  in  plaster-of-Paris.  Care  should  be  taken  that  a 
smooth,  voluminous  dressing  of  gauze  is  first  applied  to  absorb  the  abun- 
dant serosanguinous  exudate,  and  that  the  plaster  bandage  is  loose 
enough  to  allow  for  some  postoperative  swelling.  This  exudate  in- 
creases the  pressure  within  the  bandage,  and  great  care  should  be  taken 
to  watch  the  toes  or  the  fingers,  that  if  they  become  at  all  cold,  blue, 


OPEN    (or    "compound")    FRACTURES  577 

■or  edematous,  the  plaster  may  be  split  down  one  side  and  the  edges 
wedged  apart,  or,  if  necessary,  along  both  sides  ("  bivalved ") ;  straps 
of  webbing  should  then  be  buckled  around  to  keep  the  two  halves  in 
place. 

If  there  is  no  evidence  of  pressure,  the  general  pain  in  the  limb 
may  and  should  be  controlled  by  morphin  during  the  first  thirty-six 
hours.  If  the  pain  continues  more  than  thirty-six  hours,  something 
is  wrong.  Use  7io  more  morphin,  but  split  the  plaster  and,  if  necessary, 
remove  it  to  find  the  source  of  discomfort.  Often  a  little  adjusting 
of  the  padding  is  all  that  will  be  necessary.  The  circulation  miay  be 
interfered  with  so  seriously,  either  from  pressure  of  the  apparatus  or 
injury  of  vessels  from  trauma  or  subsequent  manipulation,  that  gangrene 
ensues  and  amputation  is  necessary.  We  have  seen  this  happen  in 
fracture  of  the  lower  end  of  the  femur  from  injury  to  the  popliteal 
vessels. 

If  there  are  no  signs  of  infection,  the  dressing  in  an  undrained  case 
should  not  be  removed  until  the  wound  has  healed,  that  is,  ten  days  or 
two  weeks.  Then  the  apparatus  should  be  removed,  the  wound  in- 
spected, stitches  taken  out,  and,  if  advisable,  an  .T-ray  taken  to  show 
whether  or  not  readjustment  is  necessary.  New  apparatus  should 
nov/  be  applied,  after  any  indicated  manipulation  is  performed,  to 
allov/  for  the  removal  of  the  wound  dressing,  the  reduction  of  the  post- 
operative swelling,  and  the  atrophy  of  disuse.  After  this  the  treatment 
is  that  for  closed  fractures  of  the  same  type. 

In  case  drainage  has  been  left,  as  is  frequently  the  case,  proAision 
should  be  made  for  dressing  the  wound  after  forty-eight  hours.  If 
the  fracture  has  been  put  up  in  plaster,  a  window  should  have  been  cut 
or  the  plaster  split  before  it  has  hardened,  and  the  lid  held  in  place  by 
means  of  webbing  straps  or  adhesive  plaster  until  the  proper  time 
arrives,  when  the  sheet-wadding  is  cut  away  with  scissors  and  the  dressing 
exposed.  Forty-eight  hours  is  long  enough  to  allow^  primary  infection 
to  become  apparent  in  drained  cases.  If  the  dressing  shows  nothing 
but  clean  serum,  it  is  aseptically  removed,  a  new  dressing  applied, 
the  window-lid  put  in  place  and  fixed  by  a  plaster-of-Paris  roller,  and 
the  limb  is  not  again  disturbed  until  the  ten  days  or  two  weeks  are  up. 
■Careless  technique  at  this  first  dressing  is,  without  doubt,  frequently 
responsible  for  secondary  infection  of  open  fractures  in  hospital  cases. 

A  patient  receiving  an  open  fracture,  unless  he  is  suffering  from 
some  concurrent  disease,  does  not  exhibit  any  elevation  of  tempera- 
ture if  seen  immediately.  The  temperature  after  the  operation  may 
be  expected  in  the  first  tw^enty-four  hours  to  rise  to  99.6°  F.     If  on 


578 


OPERATIONS    ON   BONES   AND   JOINTS 


the  second  day  it  continues  to  rise  over  ioo°  F.  (see  Chart,  Fig.  20,  p. 
55)  and  is  associated  with  pain,  the  presence  of  an  infection  should 
be  assumed  and  the  wound  examined.  If  sepsis  is  apparent  in  a  red- 
dening about  the  wound,  localized  superficial  tenderness,  or  a  sero- 
purulent  ooze  from  the  wound  or  the  suture  tracts,  or  if,  on  the  first 
dressing  in  drained  cases,  seropus  appears  on  the  dressing,  or  follows 
after  the  drain  when  it  is  removed,  the  case  should  at  once  be  submitted 
to  an  aggressive  routine  treatment.     The  apparatus  should  be  adapted 


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Fig.  190. — Open  Fracture  Operations. 
Aseptic  reaction  continued  over  several  days,  as  is  usual  in  these  cases. 


to  allow  easy  and  generous  access  to  the  wound.  Sutures  should  be 
removed  to  promote  unrestrained  exit  for  tissue  ooze.  The  wound 
may  have  to  be  enlarged  for  the  same  purpose.  Counteropenings 
should  be  made  for  more  efficient  drainage,  and  fenestrated  rubber 
tubes  inserted  wherever  they  will  be  of  service.  If  the  infection  is 
especially  virulent  in  its  manifestations,  through-and-through  rubber- 
tube  drainage  should  be  instituted  at  once.  Hot  antiseptic  (and  asep- 
tic)  absorbent  compresses  should  be  applied  and  renewed  every  two 


OPEN    (OR    ''compound")    FRACTURES  579 

or  four  hours,  as  the  urgency  of  the  case  demands,  day  and  night.  Later 
on,  as  the  pus  tracts  have  become  more  or  less  walled  off,  through-and- 
through  irrigation  may  be  instituted,  having  a  care  that  the  pressure 
shall  not  distribute  infected  matter  to  places  as  yet  uninfected.  In 
badly  septic  cases  continuous  warm  irrigation  or  continuous  hot  soaks 
should  be  practised  when  feasible. 

In  cases  of  frank  sepsis  the  fracture  should  be  judiciously  neglected 
for  the  time  being,  and  nicety  of  apposition  should  be  forgotten.  To 
fixate  the  part  in  something  approximating  normal  position,  and  at 
the  same  time  to  allow  ample  access  to  the  wound,  will  require  an  ap- 
paratus which  may  tax  the  ingenuity  and  the  mechanical  skill  of  the 
surgeon.  Plaster-of-Paris  is  adaptable  to  this  sort  of  dressing.  If 
there  is  but  one  sinus,  a  generously  sized  window  may  be  cut  out,  and 
if  the  plaster  is  weakened  thereby,  it  can  be  reinforced  by  ridges  of  plaster 
up  and  down  the  sides,  or  by  bridges  of  strap  iron,  with  their  extremi- 


^1 


Fig.  191. — Cabot  Posterior  Wire  Splint. 
Covered  with  bandage,  ready  for  application. 

ties  incorporated  in  the  plaster  above  and  below  the  opening.  In  cases 
of  multiple  sinuses  or  through-and-through  openings  a  separate  plaster 
can  be  put  on  above  and  below  the  wound  and  these  united  by  iron 
bridges. 

The  disadvantage  of  the  fenestrated  plaster  lies  in  the  uncleanliness 
at  the  edges  of  the  window.  The  moisture  from  the  poultices  soaks 
up  into  the  sheet-wadding,  organisms  enter  and  thrive  on  the  debris 
of  exfoliated  skin,  and  sometimes  such  air-borne  bacteria  as  the  bacillus 
of  green  pus  (Bacillus  pyocyaneus)  find  their  habitat  here  and  form 
a  disagreeable  complication.  Various  methods  have  been  devised 
to  form  a  water-tight  line  of  juncture  between  skin  and  dressing  at  the 
edge  of  the  plaster,  such  as  lining  the  plaster  with  oiled  silk  or  rubber 
dam.  The  best  scheme  of  which  we  know  is  that  described  by  Crouse.* 
He  dissolves  dental  rubber   (No.   2)   in  commercial  chloroform,   and 

*  Virginia  Med.  Semi-Monthly,  1903,  viii,  122. 


58o 


OPERATIONS    ON   BONES   AND   JOINTS 


stirs  into  this  paste  shredded  absorbent  wool.  After  drying  the  skin 
carefully  he  caulks  the  opening  between  plaster  and  skin  with  this 
mixture,  which  dries  into  an  impervious  water-tight  coating.  He 
then  applies  a  coat  of  shellac  over  the  entire  plaster. 


Fig.  iga. — Cabot  Splint. 
Pads  of  folded  pillow-slips  placed  to  fit  contoiirs  of  leg.     One  side  splint  is  in  position. 


Straps  are  in  place. 


If  there  is  much  discharge  or  if  pus  issues  from  two  or  more 
sinuses,  then  it  is  frequently  advisable  to  use  some  other  form  of  ap- 
paratus, such  as  a  Cabot  posterior  wire  splint  (Fig.  191).  This  should 
be  well  and.  comfortably  padded  and,  on  a  leg,  there  should  also  be 
well-padded  sideboards.  The  two  side  pieces  and  posterior  wire  splint, 
properly  padded,   form  a  three-sided   box  which,   strapped  together, 


Fig.  193. — Cabot  Splint. 
The  completed  application:   two  side  splints,  webbing  straps,  and  buckles. 

holds  the  leg  firmly.  Thewire  splint  with  its  foot-piece  keeps  the  foot 
at  right  angles  and  prevents  rotation  of  the  lower  fragment,  and  even 
when  taken  down  to  do  the  dressing,  maintains  the  position  of  the 
foot  with  assurance  (Fig.  192).  If  the  condition  necessitates  the  em- 
ployment of  the  hot  soak,  and  the  location  of  the  fracture  adapts  itself 


OPEN    (OR    "  COMPOUND  ")    FRACTURES 


581 


to  this  procedure,  the  wire  can  be  passed  through  rubber  tubing  before 
it  is  bent.  It  is  then  fixed  to  the  limb  by  adhesive  plaster  (which  will 
have  to  be  reenforced  frequently)  and  splint  and  the  extremity  can  be 
immersed  in  the  bath. 


Fig.  194. — Pillow- AND-siDE  Splints  Being  Applied. 
The  leg  is  laid  up  on  a  feather  pillow,  one  end  of  which  goes  just  above  the  knee.  Under,  and  at  each 
side  of,  the  leg  is  placed  a  strip  of  splint  wood,  long  enough  to  reach  from  above  the  knee  to  i  in.  below  the 
heel,  each  board  being  encased  in  a  pillow-slip.  Loops  of  muslin  bandage  are  passed  under  leg  and  splints,  and, 
while  the  assistant  is  exerting  pressure  to  approximate  the  side  boards,  these  are  drawn  tight  and  tied,  the 
middle  one  first.     Note  the  pad  of  sheet-wadding  to  protect  the  skin  from  the  tight  bandage. 

The  old-established  pillow-and-side  splint  (Fig.  194)  is  an  excellent 
temporary  apparatus  for  a  leg  fracture,  but  it  has  the  disadvantage  of 
needing  the  constant  attention  of  the  sursfeon.     The  dressing  cannot 


Fig.  195.— Pillow-and-side  Splints. 
The  loops  being  tied,  the  pillow  is  smoothed  out  and  the  overlapping  edges  pinned  together  snugly  in 
front.  The  end  of  the  pillow  projecting  below  the  foot  is  pinned  together  in  the  median  line  so  as  to  maintain 
the  foot  at  right  angles.  If  inversion  of  the  foot  is  desired,  it  can  be  gained  by  inserting  a  wide  roll  of  bandage 
between  the  lower  end  of  the  outer  splint  and  the  pillow,  and  another,  if  desired  for  counterpressure,  between 
splint  and  pillow-on  the  inner  side,  just  above  the  malleolus. 

here  be  done  by  the  nurse,  or  even  by  the  surgeon  alone,  as  each  time 
it  is  performed  the  foot  must  be  held  carefully  in  the  correct  position  by 
a  second  person,  otherwise  there  are  apt  to  be  pain  and  rotation  of  the 


582 


OPERATIONS    ON   BONES   AND   JOINTS 


lower  fragment.  If  the  wound  is  on  the  under  side  of  the  leg  or  thigh, 
nothing  is  better  than  the  Smith  anterior  splint  apparatus  (Fig.  196), 
which  keeps  the  leg  constantly  suspended  horizontally  in  such  a  way 
that  the  sinus  can  be  dressed  without  disturbing  the  patient  or  the 


Fig.  196. — Nathan  R.  Smith  Anterior  Splint. 

relation  of  the  fragments  (Fig.   197).     Unless  carefully  applied  it  is, 
however,  apt  to  be  irksome. 

Open  fractures  of  the  femur  and  of  the  humerus  can  best  be  treated 
by  extension.  For  open  fracture  of  the  femur  the  classic  Buck's  ex- 
tension is  applied,  two  long  strips  of  adhesive  plaster  extending  on 


Fig.  197. — Smith  Anterior  Splint  Applied. 

each  side  of  the  leg  from  2  inches  above  the  malleolus  up  as  far  above 
the  knee  as  the  nature  of  the  wound  allows.  They  are  held  lirmly 
to  the  leg  by  further  strips  of  adhesive  plaster  applied  spirally.  The 
leg  should  lie  naturally  on  a  posterior  splint,  extending  from  the  begin- 
ning of  the  tendo  Achillis  to  the  buttock,  padded  to  fit  the  contour  of 
the  leg.     Round  the  thigh  the  dressing  should  be  maintained  by  loosely 


OPEN    (OR    "compound")    FRACTURES  583 

applied  coaptation  splints,  held  in  place  by  straps  with  buckles,  allow- 
ing frequent  easy  removal,  if  necessary,  to  get  at  a  wound  or  sinus. 
About  20  to  35  pounds  weight  should  be  applied,  connected  by  a  pulley 
over  the  end  of  the  bed  to  the  adhesive  straps  through  the  agency 
of  a  "spreader"  acting  like  a  whiffle-tree,  2  inches  below  the  foot.  A 
T-splint  should  be  placed  along  the  outer  edge  of  the  leg,  extending  from 
4  inches  below  the  foot  to  within  6  inches  of  the  axilla,  where  it  is  held 
in  place  by  a  pocket  swathe;  the  purpose  of  this  is  to  prevent  undue 
motion  of  the  body,  not  of  the  leg.  The  straps  and  splints  should  no*; 
exert  pressure  against  any  bony  points,  especially  the  malleoli,  tip  ot 
the  heel,  the  outer  border  of  the  tibia,  and  the  patella.  The  patient 
should  lie  upon  a  Bradford  frame. 

The  complicated  modifications  of  Buck's  apparatus,  which  entirely 
conceal  the  leg,  especially  the  application  of  starch  bandages,  though 
giving  a  more  finished  appearance,  are  undesirable.  We  have  seen 
a  beautiful  apparatus,  in  which  the  leg  was  encased  from  toes  to  groin 
in  neatly  applied  starch  bandages,  on  removal  reveal  the  leg  alive  with 
maggots,  such  as  are  not  infrequent  in  neglected  septic  w^ounds.  They 
cause  no  temperature  and  often  remarkably  little  itching;  they  pos- 
sess a  characteristic  odor  which  is  not  readily  forgotten.  Maggots 
may  be  present  for  weeks  under  a  bandage  or  in  a  plaster  bandage 
without  being  suspected. 

When  a  Hoffa  table  (Fig.  52,  p.  192)  or  other  suitable  apparatus 
is  at  hand,  and  there  is  good  reason  to  suppose  the  wound  will  remain 
aseptic,  a  plaster  spica  bandage  may  be  applied  in  open  fractured 
femurs.  A  plaster  spica  is  distinctly  contraindicated  in  those  cases 
in  which  temporary  drainage  has  been  instituted  or  sepsis  is  expected, 
or  where  there  are  no  provisions  for  proper  application  of  the  apparatus. 

In  the  treatment  of  open  fracture  of  the  humerus  the  use  of  the  ex- 
tension principle  with  patient  in  bed  is  to  be  recommended.  Treat- 
ment by  ambulatory  apparatus  should  not  be  considered  until  all  danger 
of  infection  in  the  wound  is  passed.  If  at  first  an  ambulatory  apparatus 
has  been  used  and  the  wound  becomes  infected,  the  seriousness  of  the 
condition  should  be  explained  to  the  patient;  he  should  be  put  to  bed 
and  an  extension  apparatus  applied.  Under  this  form  of  treatment 
the  wound  can  be  readily  and  painlessly  dressed,  and  at  the  same  time 
the  fragments  are  maintained  in  the  best  possible  apposition. 

For  extension  of  the  arm  apply  a  strip  of  adhesive  plaster  on  each 
side  from  just  above  the  styloid  process  to  as  high  up  the  arm  as  the 
location  of  the  wound  will  permit.  Reinforce  these  with  spirally  applied 
strips  of  adhesive.   To  the  lower  end  of  each  of  the  extension  strips  a  strap 


584  OPERATIONS    ON    BONES    AND    JOINTS 

of  webbing  is  stitched,  which  passes  down  beside  the  forearm  and  hand 
to  a  spreader,  from  which  a  rope  goes  over  a  pulley  at  the  foot  of  the 
bed.  About  10  to  20  pounds  of  weight  are  applied.  The  arm  should 
lie  naturally  on  a  well-padded  splint  extending  from  the  tips  of  the 
fingers  to  the  axilla.  A  T-splint  should  be  applied  bet^'een  the  arm 
and  the  body,  on  the  same  side  as  the  injured  arm,  extending  to  the 
axilla.  It  is  held  in  place  by  a  pocket  swathe  around  the  body,  as  in 
the  femur  apparatus.  The  dressing  is  maintained  by  coaptation  splints 
lightly  held  in  place  by  straps  with  buckles  allowing  easy  removal. 

Complications  and  Sequelae. — In  open  fractures  there  exists 
an  increased  liability  to  complications,  such  as  osteomyelitis,  fat  embol- 
ism, thrombosis  and  pulmonary  embolism,  and  non-union.^  These 
must  be  borne  in  mind.  The  occurrence  of  virulent  sepsis  and  septico- 
pyemia, gas-bacillus  infection,  or  gangrene  will  frequently  indicate 
immediate  amputation  of  the  limb. 

On  account  of  the  seriousness  of  infection  in  open  fractures,  from 
the  moment  the  operation  is  completed  until  the  wound  is  firmly  united 
all  aseptic  precautions  should  be  scrupulously  employed;  dressings 
should  be  done  only  when  necessary  and  with  the  most  minute  care 
to  prevent  possibility  of  infection. 

As  moist  dressings  are  frequently  used  in  open  fractures  that  have  become 
more  or  less  infected,  a  word  of  caution  is  necessary  in  regard  to  their  prep- 
aration. In  many  hospitals  it  is  the  custom  to  use  a  basin  kept  on  the  ward 
car  for  holding  the  solution;  this  basin  is  rarely  or  never  boiled;  it  may  have 
just  been  used  to  receive  catheterized  urine  or  infected  dressings;  it  is  often  re- 
turned to  the  ward  car  with  simple  rinsing  in  cold  water.  For  the  preparation 
of  a  moist  dressing,  a  boiled  basin  should  be  insisted  upon;  if  no  large  boiling 
tank  is  in  the  ward,  it  is  a  simple  matter  to  put  the  basin  on  the  gas  stove  par- 
tially filled  with  water  and  allow  it  to  boil  for  about  five  minutes.  This  effectu- 
ally sterilizes  it.  Nurse  and  ward  attendants  should  be  made  to  realize  that 
mild  antiseptic  solutions,  weak  corrosive,  boric  acid,  alcohol,  etc.,  as  ordinarily 
employed,  will  not  sterilize  basins. 

Occasionally  it  becomes  advisable  to  give  the  infected  wound  a  hot  soak^ 
especially  in  open  fractures  of  the  small  bones  of  the  hand  that  are  infected; 
here  again  the  soak-basin  is  often  used  from  patient  to  patient  without  boiling, 
a  thing  that  ought  never  to  occur.  It  should  be  sterilized  beyond  all  possibility 
of  question  before  being  used  iii  these  cases.  Through  the  neglect  of  boiling 
dressings  and  soak-basins  we  have  seen  an  infection  travel  along  the  entire 
surgical  ward;  one  of  these  cases  died. 

^  F.  W.  Murray,  Treatment  of  Delayed  Union  by  Thyroid  Extract,  Ann.  Surg.,  1900, 
xxxi,  695. 


OPERATIVE    FIXATION    OF    FRACTURES  585 

Open  fractures  are  very  apt  to  show  a  low-grade  infection,  charac- 
terized by  the  discharge  of  3  or  4  drams  of  seropurulent  matter  daily 
for  several  weeks.  This  discharge  is  usually  maintained  by  small  free- 
lying  bits  of  dead  bone,  or  irritation  from  the  ends  of  the  fragments 
which,  denuded  of  periosteum,  become  ebonized  and  act  as  foreign 
bodies.  If  it  persists  unduly,  the  fragments  should  be  found  and  re- 
moved, or  even  the  tip  of  the  bone  may  have  to  be  removed  with  rongeurs. 

In  cases  which  have  been  discharging  for  a  long  time  and  the 
discharge  suddenly  ceases,  pocketing  of  pus  should  be  suspected,  and 
this  may  even  occur  with  little  or  no  rise  of  temperature.  The  pocket 
usually  is  in  the  fatty  connective  tissue  between  the  skin  and  muscle 
fascia.  Often  it  is  advisable  to  make  the  incision  through  the  skin, 
not  in  the  center  of  the  fluctuating  area,  but  at  a  more  dependent 
point,  to  allow  more  efficient  drainage. 

In  lower  leg  fractures,  after  the  wound  is  practically  healed  and  the 
patient  is  allowed  up  and  about  on  crutches,  blisters  are  apt  to  develop 
from  the  exudation  of  serum  as  a  result  of  the  unaccustomed  dependency 
of  the  limb  and  the  resumption  of  function.  These  sometimes  become 
infected  and  cause  repeated  breaking  down  of  the  wound.  To  fore- 
stall this  occurrence  the  plaster  should  be  split  and  the  leg  frequently 
inspected.  Blisters,  as  soon  as  formed,  should  have  the  skin  entirely 
removed  and  a  dressing  of  some  aseptic  emollient  applied. 

OPERATIVE  FIXATION  OF  FRACTURES 
(Wiring,  Saturing,  Parkhill  Clamp,  Wire  Nail,  Bone  Peg) 

Operative  methods  of  fixation  of  the  fragments  after  fracture  have 
been  in  use  for  nearly  sixty  years.  The  earliest  method  employed 
was  wiring.  In  later  years  wire  has  become  largely  replaced  by  ab- 
sorbable sutures,  because  its  presence,  acting  as  a  foreign  body,  has 
frequently  led  to  conditions  necessitating  its  removal.  Other  devices 
also  for  retention  of  the  fragments  in  apposition  have  been  devised, 
such  as  the  Parkhill  clamp,  the  w^ire  nail,  and  the  bone  peg. 

In  principle  the  mechanical  measures  are  the  same  as  for  any  cor- 
responding fracture  which  has  not  been  wired  or  sutured.  The  treat- 
ment of  the  wound  is  that  of  any  aseptic  closed  wound.  Where  wire 
has  been  used  and  there  is  persistent  suppuration,  the  wire  must  be 
cut  down  upon  and  removed. 

The  Parkhill  Clamp. — This  was  first  presented  by  Parkhill  in 
1897.^     Briefly  described,  it  consists  of  four  screws,  two  of  which  are 

^  Trans.  Amer.  Surg.  Assoc,  1897,  xv,  257. 


586 


OPERATIONS   ON   BONES   AND   JOINTS 


inserted  into  each  fragment,  and  the  four  held  together  by  a  clamp 
outside  the  wound.  The  incision  is  closed  except  for  the  passage  of  the 
four  screws,  and  covered  with  sterilised  gauze,  which  is  passed  beneath 
and  round  the  clamp,  and  the  limb  inclosed  in  plaster.  At  the  end  of 
ten  days  the  wound  is  dressed  through  a  window  in  the  plaster  and 
the  stitches  removed.  The  plaster  is  omitted  at  the  end  of  from  four 
to  six  weeks  in  the  smaller  bones,  or  eight  weeks  in  the  case  of  the  femur, 
and  the  clamp  is  then  removed  and  the  screws  easily  taken  out  of  the 
bone.  The  screw-holes  are  covered  with  sterile  gauze  for  a  few  days 
until  they  are  closed  in.  In  all  bones  except  the  femur  the  union  by 
this  time;  is  sufficient  to  allow  use.  The  femur  should  be  again  put 
up  in  plaster  for  three  weeks,  and  weight-bearing  is  not  allowed  until 
the  end  of  the  twelfth  week.  This  idea  has  received  many  modifica- 
tions, one  of  which  (by  Dr.  F.  J.  Cotton,  of  Boston)  is  shown  in  Fig.  198. 


■1 


Fig. 


-F.  J.  Cotton's  Method  in  Open  Fractdre  of  the  Femur. 


Blunt  steel  screws  are  screwed  into  the  outer  aspect  of  the  shaft  of  the  bone  in  a  straight  line,  two  in 
the  upper  and  two  in  the  lower  fragment.  Their  ends,  which  are  allowed  to  project  from  the  wound,  are 
bolted  through  holes  in  a  strip  of  hard  wood. 

The  Wire  Nail. — This  finds  its' chief  use  in  fractures  of  the  neck 
of  the  femur.  Silver  nails,  screws,  and  ivory  pegs  have  also  been  used 
in  the  same  manner.  According  to  Sir  William  McCormack,^  the 
first  operation  of  this  character  was  done  by  v.  Langenbeck.  The 
first  in  America  was  done  by  Willy  Meyer.^  The  largest  number  of 
cases  reported  by  any  one  man  was  reported  by  Nicolaysen,^  who  had 
performed  21. 

Nicolaysen's  technique  differs  from  that  employed  by  most  of  the 
other  operators  in  that  the  nail  is  simply  driven  in  through  the  skin 
without  making  an  incision.  The  nail  is  wound  about  with  sterile 
gauze  and  a  plaster  spica  is  applied  reaching  from  the  iliac  crests  to 

^  Antiseptic  Surgery,  London,  1880,  200. 

^  Ann.  Surg.,  1893,  x\dii,  30. 

^Nord.  Med.  Ark.,  Stockholm,  1897,  \'iii,  i;    also  ibid.,  1899,  x,  i. 


OPERATIVE   FIXATION   OF   FRACTURES  587 

the  toes.  At  the  end  of  four  weeks  a  window  is  cut  o\-er  the  trochanter, 
and  the  nail,  which  is  ahvays  loose,  is  removed.  At  the  end  of  eight 
to  ten  weeks  the  plaster  is  removed  and  the  patient  gotten  up  on  crutches. 
At  the  end  of  three  months  weight-bearing  is  begun.  The  after-treat- 
ment of  cases  in  which  an  incision  has  been  employed  is  substantially 
the  same.  The  incision  is  closed  without  drainage  and  a  sterile  dressing 
applied.  On  the  tenth  day  a  window  is  cut  in  the  plaster  and  the 
stitches  removed.  Some  surgeons  cut  down  upon  the  nail  under  cocain 
and  remove  it  at  the  end  of  six  weeks.  Others  leave  it  in  situ  indefi- 
nitely. 

This  operation  seems  to  be  remarkably  free  from  complications. 
In  36  cases  collected  by  H.  Augustus  Wilson  ^  the  only  complication 
was  suppuration  in  the  wound,  which  occurred  in  one  case. 

Bone  pegs  and  ferrules  w-ere  introduced  by  Senn.^  They  have 
the  advantage  of  being  absorbable.  The  after-treatment  is  the  same  as 
for  the  suturing  of  a  fracture  with  any  absorbable  material. 

Operation  for  Fractured  Patella. — Operative  treatment  of 
this  condition  has  shown  a  constant  tendency  to  simplification.  Elabo- 
rate methods  of  application  of  silver  wire  have  fallen  into  disuse. 
It  is  now  fairly  well  established  that  the  lateral  tears  in  the  capsule 
are  of  importance,  and  that  careful  approximation  of  torn  edges  of  the 
capsular  ligaments  is  of  more  value  than  strong  suture  material  ap- 
proximating bone.  The  liability  of  the  synovia  to  infection  is  generally 
considered  greater  than  that  of  the  peritoneum.  The  knee  should 
be  opened  with  as  much  respect  as  the  cranial  cavity. 

After  the  dressing,  either  a  plaster-of-Paris  bandage  should  be 
applied  from  above  ankle  to  groin,  or  a  long,  well-fitting  ham  splint 
may  be  used.  In  either  case,  enough  padding  should  be  put  in  the 
popliteal  space  to  avoid  hyperextension,  which  is  unnecessary  and 
uncomfortable. 

The, skin  sutures  should  be  removed  at  the  end  of  ten  days;  the 
wound  is  then  reinforced  with  plaster  straps  and  the  splint  continued. 

Four  weeks  from  operation,  passive  motion,  slight  and  gentle  at 
first,  is  begun,  and  two  weeks  later  use  of  the  leg  may  be  begun  ^^ith 
only  a  flannel  bandage  over  the  knee.  From  that  time  on  further 
motion  of  the  joint  should  be  encouraged,  and  at  the  end  of  the  eighth 
week  may  be  forced  to  a  degree  short  of  painful.  The  flannel  bandage, 
if  necessary,  from  ankle  up,  should  be  worn  until  the  tendency  to  edema 
of  the  leg  disappears — possibly  three  months. 

^  Wilson,  Amer.  Jour.  Orthopedic  Surg.,  iQoy-oS,  v,  339. 
^  Ann.  Surg.,  1893,  xviii,  125. 


588  OPERATIONS    ON    BONES    AND    JOINTS 

Complications  and  Sequelae. — Sepsis. — Infection  of  the  skin 
should  be  suspected  if  slight  temperature  persists  or  if  there  is  super- 
ficial tenderness  through  the  dressing.  Prompt  detection  and  atten- 
tion to  such  infection  often  precludes  the  disaster  of  deep  infection. 
Infection  of  the  knee-joint  is  one  of  the  most  serious  calamities  of  sur- 
gery, and  can  be  met  only  by  prompt  opening  of  the  wound,  washing 
out  with  saline,  and  efl&cient  drainage.  The  joint  is,  of  course,  neces- 
sarily sacrificed,  and  more  than  that,  the  infection  is  so  serious  that 
life  is  often  held  in  the  balance.^ 

Persistent  Adhesions. — This  condition  is  met  as  after  operations 
for  dislocated  cartilage,  but  force  must  be  applied  with  good  judgment, 
lest  separation  of  the  newly  healed  patella  take  place. 

Suture  of  the  Olecranon. — The  wound  is  closed  wdthout 
drainage,  and  the  arm,  in  extension,  put  up  in  a  plaster  reaching  from 
the  axilla  to  the  ends  of  the  metacarpal  bones.  The  wound  is  dressed 
and  the  stitches  removed  through  a  window  in  the  plaster  at  the  end 
of  ten  days.  The  plaster  is  taken  off  at  the  end  of  four  weeks  and 
passive  motion  begun. 

OPERATIONS  ON  THE  KNEE:    DISLOCATED    CARTILAGE,  SYNOVIAL 

FRINGE 

The  after-care  is  made  most  simple  if  the  joint  has  been  opened  by 
a  lateral  curved  incision,  convex  fonvard  in  the  skin,  and  a  transverse 
incision  of  the  capsule  itself,  the  latter  part  going  backward  beyond  the 
middle  of  the  tuberosity.  If  this  method  of  entering  the  joint  is  used,  the 
skin  heals  freely  movable  over  the  deep  scar,  and  there  is  not  presented 
a  single  healing  plane  from  skin  to  knee-joint,  with  the  dangers  cf 
direct  infection.  With  this  method  of  incision,  then,  or  a  direct  vertical 
incision,  the  joint  need  only  be  splinted  after  the  application  of  the 
dressing  by  four  rolls  of  cotton  wadding,  each  2  inches  in  diameter 
and  2  feet  long,  placed  equidistant  about  the  joint,  parallel  with  the  leg. 
Such  a  method  of  splinting  will  allow  the  knee  to  rest  in  a  comfortable 
position — that  is  to  say,  slightly  flexed — and  will  allow  slight  miovement 
from  the  start.  Troublesome  adhesions  are  much  less  liable  to  form. 
The  skin  stitches  are  removed  in  ten  days.  All  splints  are  then  re- 
moved, a  flannel  bandage  is  applied,  and  passive  motion  is  begun. 
Four  days  later  active  motion  should  be  tried  and  the  patient  should 
be  encouraged  to  get  about,  using  crutches  or  two  sticks  at  first.     When 

*  David  D.  Scannell,  Boston  Med.  and  Surg.  Jour.,  1906,  civ,  568.  Sepsis  after  this 
operation  should  be  rare:  witness  an  exceedingly  dirty  open  fracture  of  the  patella,  which> 
conscientiously  cleaned,  healed  by  first  intention. 


RECURRENT   DISLOCATION    OF    THE    SHOULDER  589 

the  leg  is  first  hung  down,  edema  of  the  foot  and  leg  may  appear.  A 
flannel  bandage  from  foot  to  above  knee-joint  will  control  this  within 
a  week  in  a  vigorous  person. 

Complications  and  Sequelae. — Sepsis. — Infection  of  the  skin 
around  the  wound  may  be  easily  met  and  overcome.  Any  persistent 
temperature,  tenderness,  or  pain  should  lead  to  immediate  investiga- 
tion of  the  wound,  even  as  early  as  the  second  day.  Skin  infection 
may  thus  be  checked  where  it  is,  before  it  penetrates  the  capsule.  In- 
fection of  the  knee-joint  is  a  disaster  covered  under  Suture  of  Patella 

(P-  587)- 

Adhesions. — The   knee   after   this   operation   is   always   limited   in 

motion  at  first.     After  the  twenty-first  day  passive  motion  should  force 

flexion.     The  thigh  should  be  put  over  the  knee  of  the  surgeon  or  over 

the  arm  of  a  chair,  and  the  leg  gently  but  firmly  flexed,  gaining  a  little 

each  day.    For  active  motion,  the  patient  should  stand  and  slowly  stoop, 

thus  forcing  flexion  with  his  body  weight.     To  these  procedures  may 

be  added  intelligent  massage  and,  at  times,  baking  may  be  helpful. 

For  obstinate  cases  flexion  may  be  brought  about  by  special  apparatus, 

such  as  that  of  Zander. 

OPERATION   FOR   RECURRENT    DISLOCATION    OF   THE    SHOULDER 

Up  to  1894  excision  of  the  head  of  the  humerus  was  the  method  of 
treatment  in  vogue  for  recurrent  dislocation  of  the  shoulder,  although 
Gerster  ^  makes  casual  reference  to  a  case  operated  upon  by  him  in 
1883,  in  which  he  excised  a  portion  of  the  capsule  of  the  joint.  *  In 
1894  Ricard  ^  reported  2  cases  successfully  treated  by  taking  a  reef  in 
the  capsule. 

To  Burrell^  is  due  the  credit  of  originating  and  perfecting  the  technique 
of  shortening  the  capsule  by  partial  excision  and  suture,  which  he  de- 
scribed in  1897,  with  the  report  of  two  successful  cases.  The  advantage 
of  Burrell's  method  over  Ricard's  is  obvious,  since  the  former  allows 
exploration  of  the  interior  of  the  shoulder-joint  and  the  removal  of 
loose  bodies  which  are  occasionally  found. 

The  after-treatment  of  both  Burrell's  and  Ricard's  operations  is 
identical.  The  capsule  is  sutured  with  catgut,  the  muscles  brought 
together,  and  the  skin  \vound  closed  with  silkworm-gut.  A  dry  sterile 
dressing  fixed  with  collodion  or  plaster  straps  is  applied  and  the  arm 
put  up  in  a  Velpeau,  with  the  elbow  elevated  and  carried  inward  to 

^  Rules  of  Aseptic  and  Antiseptic  Surgen-,  New  York,  1888,  8. 
^  Bull,  de  I'acad.  de  med.,  1894,  N.  S.,  xxxi,  330. 
^  Amer.  Jour.  Med.  Sci.,  1897,  N.  S.,  cxiv,  166. 


59°  OPERATIONS    ON   BONES   AND   JOINTS 

ward  the  median  line.  The  arm  is  not  disturbed  until  the  tenth  day, 
when  the  first  dressing  is  done  and  the  stitches  removed.  The  Velpeau 
is  replaced  and  continued  until  four  weeks  from  the  date  of  operation, 
when  massage  and  passive  motion  are  begun,  and  the  patient  is  allowed 
to  return  to  work  at  the  end  of  eight  weeks. 

OPERATION  FOR  PURULENT  ARTHRITIS 

It  will  be  assumed  that  no  joint  is  incised  for  drainage  unless  the 
presence  of  infected  fluid  has  been  determined  by  needle  puncture. 
The  knee  will  be  drained  by  an  incision  each  side  of  the  patella.  The 
ankle  will  be  drained  by  an  incision  just  in  front  of  each  malleolus. 
The  wrist  will  be  drained  by  an  incision  over  each  styloid  process. 
For  these  three  joints  through-and-through  drainage  will  be  established 
by  a  single  piece  of  rubber  dam.  The  elbow,  shoulder,  and  sterno- 
clavicular joint  are  drained  by  a  single  incision,  the  rubber  dam  being 
held  in  by  a  single  stitch  through  it  and  the  skin. 

The  best  dressing  for  drainage  undoubtedly-  is  the  salt  and  citrate 
poultice.  The  rubber  dam  is  withdrawn  in  from  forty-eight  to  ninety- 
six  hours.  The  poultices  are  maintained  one  or  two  days  longer  if 
the  temperature  has  not  reached  normal.  Passive  motion  should  be 
begun  by  the  fifth  day,  unless  the  process  is  still  very  active  and  painful, 
and  continued  in  increasing  duration  daily. 

OSTEOMYELITIS 

For  our  earliest  conception  of  the  regeneration  of  bone  from  perios- 
teum we  are  indebted  to  Oilier.^  His  technique  was  carried  out  with  suc- 
cessful issue  in  two  cases  of  suppurative  periostitis  by  Cheever  in  1868.^ 
The  pathology  of  the  present  method  of  the  treatment  of  osteomyelitis, 
by  early  resection  of  the  necrotic  bone,  allowing  regeneration  from  the 
periosteum,  was  first  outlined  by  E.  H.  Nichols  in  1898,^  and  his  sugges- 
tions were  carried  out  by  Dr.  Hayward  W.  Gushing.*  For  an  exhaus- 
tive description  of  the  pathology  of  osteomyelitis  and  the  technique  of 
operation,  the  reader  is  referred  to  the  masterly  article  read  by  Nichols^ 
at  the  meeting  of  the  American  Medical  Association  in  1903. 

^  Traite  Experimentale  et  Clinique  de  la  Regeneration  des  Os,  et  de  la  production 
artificielle  du  Tissue  Osseux,  Paris,  1867. 

^  Reproduction  of  the  Tibia,  Med.  and  Surg.  Reports  of  the  Boston  City  Hospital, 
1870,  i,  362. 

^  Communication  Mass.  Med.  Soc,  1898,  xvii,  875. 

*  Ann.  Surg.,  1899,  xxx,  468. 

^  Jour.  Amer.  Med.  Assoc,  1904,  xlii,  439. 


OSTEOMYELITIS  591 

The  consideration  of  the  after-treatment  may  be  divided  into  that — 
(i)  Of  the  acute  stage;  (2)  of  the  subacute;  and  (3)  of  the  chronic. 

Acute  Stage. — In  the  acute  stage  there  is  more  or  less  extensive 
suppuration  in  the  marrow  The  pus  is  evacuated  by  incision  of  the 
soft  parts  and  removal  of  a  portion  of  the  cortex  of  the  bone.  The 
wound  is  packed  with  iodoform  gauze  and  a  few  stitches  taken  at  the 
extremities.  A  moist  citrate  salt  dressing  is  applied  and  the  limb  im- 
mobilized by  a  splint.  The  dressing  is  done  at  the  end  of  forty-eight 
hours  and  daily  thereafter.  At  each  dressing  the  cavity  is  irrigated 
with  chlorinated  soda  solution  (i :  80)  and  repacked.  In  exceptional 
cases  the  bone  regenerates  completely  and  the  w^ound  heals  spontane- 
ously. Usually,  however,  a  sequestrum  forms,  which  must  be  removed 
by  a  secondary  operation. 

Subacute  Stage. — This  secondary  operation  in  the  case  of  bones 
having  an  accessory  bone  to  serve  as  a  splint,  as  the  tibia,  should  be 
performed  while  the  periosteum  is  still  plastic,  but  has  begun  to  ossify 
in  its  deeper  layers — ordinarily  about  eight  weeks  after  drainage  of  the 
acute  suppuration.  In  the  case  of  bones  like  the  humerus,  which  have 
no  such  accessory  support,  it  is  necessary  to  wait  until  the  regenerating 
periosteum  has  obtained  sufficient  stiffness  to  prevent  distortion  by 
muscular  pull,  but  not  long  enough  to  allow  the  periosteum  to  have 
lost  its  power  of  central  growth.  The  proper  time  for  operation  may 
be  estimated  by  the  thickness  of  the  involucrum,  the  rule  given  by 
Nichols  {loc.  cit.)  being  to  operate  when  the  total  diameter  of  the  in- 
volucrum is  about  equal  to  one-half  the  diameter  of  the  normal  shaft. 
This  is  usually  about  twelve  weeks  after  the  drainage  of  the  abscess- 
cavity. 

The  after-treatment  of  operations  on  both  types  of  bone  is  identical, 
the  later  operation  requiring  as  much  time  for  regeneration  as  the 
earlier.  The  wound  is  closed  w^ith  or  without  drainage,  according  to 
the  amount  of  discharge  from  the  cavity  before  operation,  a  moist  anti- 
septic dressing  is  applied,  and  the  limb  immobilized  in  plaster.  The 
patient  is  kept  in  bed  about  two  weeks  when  a  bone  of  the  upper  ex- 
tremity is  involved,  but  the  plaster  is  continued  for  about  six  months, 
after  which  regeneration  should  be  complete  enough  to  begin  use.  In 
bones  of  the  lower  extremity,  the  patient  is  allowed  up  on  crutches 
and  a  high  sole  at  the  end  of  six  to  eight  weeks,  but  the  plaster  is  con- 
tinued until  from  six  to  eight  months,  after  which  it  is  removed  and 
weight-bearing  gradually  begun.  Small  sinuses  may  form  during  the 
convalescence  from  one  of  these  operations  and  require  curetting,  but 
usually  they  will  eventually  heal  without  further  difficulty. 


592  OPERATIONS    ON    BONES    AND    JOINTS 

Chronic  Stage. — In  the  chronic  cases  the  sequestrum  becomes 
surrounded  by  a  wall  of  dense  bone  which  has  no  power  of  central 
growth,  and  its  removal,  therefore,  is  not  followed  by  closure  of  the 
cavity.  Various  procedures  have  been  devised  for  this  purpose,  Hamil- 
ton ^  tried  to  graft  in  pieces  of  sponge  in  the  hope  that  they  would  serve 
as  a  framework  for  the  formation  of  the  new  bone,  but  this  method  has 
proved  an  utter  failure. 

Schede  ^  disinfected  the  cavity  as  thoroughly  as  possible,  allowed 
it  to  fill  up  with  blood,  and  then  sutured  the  skin  over  the  top,  allowing 
the  blood-clot  to  organize  and  the  cavity  in  this  way  to  become  filled  in 
with  fibrous  tissue.  In  spite  of  the  obvious  difiiculties  in  the  way  of 
rendering  the  cavity  sterile,  this  method  has  sometimes  proved  success- 
ful. The  best  method  is  that  of  Neuber,^  who  cleans  out  the  ca\-ity, 
draws  in  the  adjacent  skin  and  soft  parts,  and  nails  or  sutures  them  to 
the  bottom  of  the  cavity,  thus  lining  it  with  skin. 

The  Mosetig-Moorhof  method  ■*  consists  in  rendering  the  canity 
as  nearly  aseptic  as  possible,  drying  it,  and  filhng  it  with  a  mixture  of — 

Iodoform 60  parts 

Spermaceti 40  parts 

Oil  of  sesame 40  parts 

which  is  poured  in  warm  and  then  hardens  and  hermetically  seals  the 
cavity.  The  soft  tissues  are  then  sutured  over  it.  The  originators 
reported  120  cases  successfully  treated  by  this  method.  Nichols,'"  how- 
ever, has  not  seen  such  satisfactory  results. 

OPERATIONS  FOR  BOW-LEGS,  KNOCK-KNEES,  AND  COXA  VARA 

These  will  be  considered  together  for  the  sake  of  convenience. 
Two  forms  of  operation  are  in  use — osteoclasis  and  osteotomy.  The 
former  is  employed  in  the  ordinary  outward  bowing  of  the  femur. 
The  latter  is  the  method  of  choice  when  the  deformity'  is  in  close  rela- 
tionship with  a  Joint,  as  in  knock-knees  or  coxa  vara,  or  where  both 
anteroposterior  and  lateral  bowing  are  present.  Osteotomy  is  done 
at  various  levels,  being  called  Gant's  operation  when  done  below  the 
trochanters;  Macewen's,  above  the  condyles;  and  Trendelenburg's, 
when  both  the  tibia  and  fibula  are  sawn  through  just  above  the  mal- 
leoli. 

^  Edinburgh  Med.  Jour.,  1881,  xx^^i,  385. 
2  Deut.  med.  Woch.,  1886,  xii,  389. 
^  Arch.  f.  klin.  Chir.,  1879,  xxv,  316. 
*  Centralbl.  f.  Chir.,  1903,  xxx,  433. 
^  Keen's  Surgery,  Phila.,  1909,  ii,  43. 


CLUB-FOOT    (CONGENITAL   EQUINOVARUS)  593 

The  after-treatment  is  the  same  for  both  osteoclasis  and  osteotomy, 
except  after  Gant's  operation.  Plaster  bandages  extending  from  the 
groins  to  the  toes  are  applied,  maintaining  the  Hmb  in  the  corrected 
position,  and  are  worn  for  four  weeks,  and  then  cut  along  each  side 
so  that  they  may  be  taken  off  at  night.  At  the  end  of  six  weeks  they 
may  be  removed  entirely  and  weight-bearing  begun  if  the  union  is  firm. 
After  subtrochanteric  osteotomy  a  double  plaster  spica  extending  to 
the  ankles,  applied  with  the  limbs  in  abduction,  is  worn  for  six  weeks, 
then  omitted  at  night  for  two  weeks  more,  and  finally  left  off  altogether 
at  the  end  of  the  eighth  week,  at  which  time  weight-bearing  may  be 
commenced. 

Complications  and  Sequelae. — These  operations  are  seldom 
-accompanied  by  special  complications.  Delay  in  union  sometimes 
occurs  after  osteotomy  and  requires  a  longer  period  of  fixation  in  plaster, 
together  with  efforts  to  influence  nutrition.  In  children,  the  frequently 
coexisting  rachitis  must  be  treated.  Recurrence  of  the  deformity 
sometimes  takes  place  and  necessitates  a  repetition  of  the  operation. 

CLUB-FOOT  (CONGENITAL  EQUINOVARUS) 

The  operation  may  consist  in — (i)  manual  correction;  (2)  sub- 
cutaneous tenotomies;  (3)  open  division  of  the  resistant  structures 
(Phelps) ;  (4)  forcible  correction  with  instruments,  and  (5)  bone  opera- 
tions. In  any  case,  the  foot  should  be  held  overcorrected  in  plaster- 
of-Paris  for  four  to  tw^elve  weeks,  depending  on  the  age  of  the  patient 
and  the  degree  of  deformity.  The  patient  should  then  be  fitted  with 
a  Taylor  club-foot  shoe;  in  an  infant  the  plaster  should  be  continued, 
removing  it  at  intervals  to  allow  of  manipulation,  until  he  is  old  enough 
to  walk,  when  a  brace  should  be  applied. 

The  following  technique  of  plaster  application,  recently  described 
by  Ehrenfried,^  is  particularly  adaptable  to  the  postoperative  treatment 
of  infants  and  young  children: 

"The  plaster  is  applied  from  thigh  to  tips  of  toes,  with  the  knee  flexed, 
so  as  to  prevent  the  cast  from  twisting  on  the  leg,  and  allowing  a  return  of  the 
varus  deformity.  The  skin  should  be  clean  and  dry  and  well  powdered,  and 
the  foot  and  leg  should  be  evenly  and  snugly  padded  with  narrow  sheet-wad- 
ding. The  bony  prominences  should  be  generously  covered,  but  if  too  much 
wadding  is  used,  it  is  likely  to  pack  together,  so  that  the  foot  and  leg  become 
loose  in  the  cast. 

"  If  the  plaster  is  applied  to  the  best  advantage,  three  2-inch  rolls  are  ample 
in  a  young  infant,  and  four  3 -inch  bandages  will  suffice  for  an  older  child.  Of 
^  Boston  Med.  and  Surg.  Jour.,  igog,  rlxi,  741. 


594 


OPERATIONS    ON    BONES    AND    JOINTS 


the  first  roll,  half  is  used  in  making  a  collar  about  the  forefoot.  This  is  so 
applied — the  foot  hanging  relaxed — with  circulars  and  reverses,  as  to  lie  snugly 
against  the  foot.  It  should  extend  to  the  tips  of  the  toes,  but  should  not  cramp 
them  or  hide  their  extremities.  It  should  fit  closely  against  the  inner  border 
of  the  great  toe,  to  its  very  tip,  so  as  to  give  efficient  leverage  in  abduction. 
The  remainder  of  the  roll  is  applied  in  circular  turns  about  the  thigh,  carried 
as  high  up  as  possible. 

"  No  further  plaster  is  applied  until  the  collar  has  set.  When  this  has  be- 
come solid,  one  can  efficiently  manipulate  the  forefoot  as  a  unit  and  apply  a 
considerable  amount  of  force  without  cramping  or  dislocating  the  toes,  or  caus- 
ing pressure  sloughs,  for  the  pressure  is  not  concentrated,  but  is  distributed 
evenly  through  the  collar  (Fig.  199). 

"  The  second  roll  is  applied,  after  six  or  eight  minutes,  in  the  form  of  circular 
turns  over  the  thigh  and  under  the  ball  of  the  foot.     These  turns  are  drawn. 


Fig.  199. — Diagram  Showing  Advantage  in  Applying  a  Collar  and  Allowing  it  to  Set  Before  At- 
tempting TO  Maintain  Position  over  Old  Method  of  Attempting  to  Overcorrect  With  Plaster 
still  Wet  (Ehrenfried). 


as  tightly  as  possible,  with  the  object  in  view  of  flexing  the  knee  and  dorsiflexing 
the  foot  at  acute  angles.  If  the  bandage  goes  high  up  on  the  thigh  and  far  out 
on  the  foot,  there  will  be  a  considerable  leverage  at  the  command  of  the  operator 
(Fig.  200).  This  roller  should  always  be  applied  in  such  direction  that  the 
turns,  when  drawn  tight,  will  naturally  assist  in  elevating  the  outer  border  of  the 
foot  and  maintaining  eversion,  thus:  on  the  right  leg  the  plaster  should  be 
applied,  as  ordinarily,  in  the  direction  of  the  hands  of  a  clock;  on  the  left,  in  the 
reverse.  The  last  inches  of  this  roller  should  be  used  in  making  a  tight  circular 
or  two  about  the  calf  to  draw  the  plaster  which  has  just  been  applied  close  in  to 
the  leg. 

"  The  third  roller  is  put  on  immediately  and  is  used  to  cover  in  the  knee  and 
heel,  which  have  not  yet  been  touched.  The  plaster  here  need  not  be  thick,  as 
it  is  not  essential  in  maintaining  the  position;  and  for  the  sake  of  lightness  it 
had  best  be  applied  in  recurrent  turns  (Figs.  201  and  202). 


CLUB-FOOT    (CONGENITAL   EQUINOVARUS) 


595 


"  A  plaster  applied  in  this  way  will  hold  all  the  correction  which  can  be 
gained  by  manipulation,  with  the  exception  of  abduction.  To  obtain  this, 
the  foot  should  be  held  abducted  while  the  plaster  is  drying.  In  holding  the 
position  care  should  be  taken  not  to  indent  the  plaster  with  the  fingers,  or  a 
slough  may  result.  After  it  has  dried  sufficiently  to  maintain  its  own  position, 
any  trimming  which  may  be  necessary  about  the  toes  is  performed,  and  it  is 
a  good  rule  also  to  split  the  plaster  part  way  down  the  outer  side,  so  as  to  allow 
of  its  being  removed  more  readily  in  case  of  emergency  or  when  the  proper 
time  arrives. 


Fig.  200. — Diagram  Showing  the  Advantage  of  Circular  Turns  Over  the  Thigh  and  Under  the 
Foot  in  Gaining  and  Maintaining  the  Greatest  Possible  Amount  of  Dorsiflexion  (Ehren- 
fried). 

"  The  child  is  not  allowed  to  depart  until  it  is  certain,  from  the  color  of  the 
toes,  that  there  is  no  interference  with  circulation;  and  the  mother  is  instructed 
to  bring  the  baby  immediately  or  remove  the  plaster  herself  if  the  toes  become 
white  or  blue.  In  a  resistant  foof,  where  considerable  pressure  may  have  to 
be  exerted,  there  is  always  some  danger,  but  with  this  form  of  plaster  it  is  at 
a  minimum  because  there  is  no  pressure  from  plaster  under  the  popliteal  space 
or  in  the  bend  of  the  ankle." 


Complications  aud  Sequelae. — Slough 
circulation  from  pressure  of  the  plaster. 


and   interference   with 


596  OPERATIONS    ON    BONES    AND    JOINTS 


Fig.  201. — Plaster  Applied,  Side  View  (Ehrenfried). 


Fig.  202.— Plaster  Applied,  Front  View. 

The  extreme  degree  of  overcorrection— the  foot  being  directed  outward  and  upward,  and  the  outer  border 
elevated — is  apparent  (Ehrenfried). 


OPERATIOX    FOR    SPINA    BIFIDA  597 

Rigid  foot,  depending  sometimes  on  maintaining  the  foot  too  long 
in  plaster  without  manipulation,  and  sometimes  resulting  necessarily 
from  the  operation. 

Recurrence  of  the  deformity.  This  latter  complication  is  practically 
bound  to  occur  unless  the  postoperative  care  is  followed  out  with  the 
utmost  patience  and  assiduity.  The  foot  must  be  retained  in  over- 
correction by  plaster  or  apparatus,  in  marked  cases,  for  two  years  in 
children  and  one  year  in  adults;  if  by  plaster,  the  bandage  must  be 
changed  every  t^vo  weeks  to  allow  of  manipulation.  The  patient  should 
be  kept  under  observation  for  a  year  or  two  longer.  The  tendency  to 
toe-in  must  be  opposed. 

HALLUX  VALGUS 

The  operation  of  Weir,  whereby  the. exostosis  is  removed  and  the 
severed  dorsal  tendon  is  sewed  into  the  side  of  the  phalanx,  and  W. 
J.  Mayo's  operation,  whereby  the  exostosis  is  removed  and  the  bursa 
is  turned  in  to  make  a  new  joint  surface,  are  the  two  best  operations. 
For  either,  the  curved  incision,  convex  downward,  has  the  best  blood 
supply,  and,  therefore,  heals  best.  The  objection  that  the  shoe  will 
press  against  the  scar  so  placed  is  theoretic  only.  A  wad  of  cotton  is 
placed  between  the  great  and  next  toe.  No  splint  need  be  applied; 
the  bed-clothes  should  be  so  held  up  that  their  weight  shall  not  come 
on  the  toes.  The  patient  may  get  out  of  bed  on  the  second  day,  but 
the  leg  should  be  kept  horizontal  for  a  week.  At  the  end  of  ten  days 
the  stitches  should  be  taken  out  and  walking  should  be  attempted.  The 
pledget  of  cotton  should  be  kept  between  the  toes  for  four  weeks  at 
least.  Right  and  left  stockings  should  be  used,  if  obtainable,  and 
flexible  anatomic  shoes  should  be  prescribed.     (See  Chap.  XXXVI,  p. 

3150 

OPERATION  FOR  SPINA  BIFIDA 

After  operations  for  spina  bifida  the  one  great  essential  to  success 
is  the  prevention  of  infective  material  entering  the  wound.  When  the 
defect  is  at  the  lower  end  of  the  spine,  in  close  proximity  to  the  rectum, 
and  the  skin  over  the  sac  is  already  macerated  and  septic,  this  is 
far  from  easy,  and  requires  the  utmost  care  and  watchfulness  on  .  the 
part  of  the  nurse.  The  wouiid  is  closed  tightly  with  continuous  cat- 
gut, reinforced  by  a  iew  silkworm-gut  sutures.  An  alcohol  dressing 
is  applied'and  held  in  place  by  a  tight  band.  Outside  of  this  a  second 
dressing  is  placed,  which  can  be  changed  as  often  as  soiled.  The  inner 
dressing  must  be  changed  about  every  other  day  because  of  the  con- 
dition of  the  skin  and  the  danger  of  the  gauze  becoming  soiled.     The 


598  OPERATIONS    OX    BOXES    AXD    JOIXTS 

silkworm-gut  stitches  are  taken  out  at  the  end  of  a  week.  The  nursing 
or  feeding  of  the  infant  must,  of  course,  go  on  as  before  the  operation. 
A  temiperature  during  the  first  day  or  t^vo  of  the  convalescence,  even  of 
105°  F.,  does  not  necessarily  indicate  any  serious  complication.  The 
same  is  true  of  rise  in  the  pulse-rate.  Of  much  more  im^portance  is  the 
way  the  child  takes  nourishment.  A  refusal  to  nurse  or  take  the  bottle 
is  often  the  forerunner  of  a  serious  complication. 

Complications  and  Sequelae. — Lovett  ^  has  reported  24  per- 
sonal cases  with  a  mortality  of  37^  per  cent.,  11  of  which  were  in  private 
practice,  with  only  2  deaths.  He  collected  88  cases  from  the  literature, 
with  T,o  deaths. 

(i)  Meningitis. — This  is  an  extremely  serious  complication,  and 
results  from  infection,  vv'hether  at  the  time  of  operation  or  entering 
the  wound  aften^'ard.  Twitching  of  the  face,  eyelids,  or  hands  should 
be  treated  by  the  injection  of  chloral  (i  gr.  for  an  infant  of  one  month) 
or  potassium  bromid  (5  gr.  at  one  month)  by  rectum,  repeated,  if  neces- 
sary, every  hour  for  three  doses.     Tapping  of  the  ventricles  is  useless. 

(2)  Leakage  of  Cerebrospinal  Fluid. — If  this  cannot  be  controlled 
by  pressure,  an  additional  suture  must  be  inserted  in  the  wound,  for 
unless  this  leakage  can  be  stopped,  death  is  almost  inentable. 

(3)  Superficial  Infection  of  the  W oiind .^l^oxtit  (loc.  cit.)  stated 
that  he  had  met  with  a  few  cases  of  superficial  infection,  in  none  of 
which  had  the  wound  broken  down  or  any  other  serious  complication 
occurred. 

(4)  Later  Complications. — An  operation  for  spina  bifida  cannot  be 
considered  as  successful  until  after  the  elapse  of  at  least  three  years, 
since  within  this  time  many  of  the  children  die  from  hydrocephalus, 
convulsions,  or  intestinal  complications.  Sachtleben  -  gives  this  secon- 
dary mortality  as  29  per  cent. 

LAMINECTOMY 

The  dura  is  closed  without  drainage,  but  a  gauze  or  cigarette  drain 
is  placed  down  to  the  dura,  and  the  aponeurosis,  muscle,  and  skin  are 
closed  except  at  this  point.  The  skin  sutures  are  of  silkworm-gut. 
A  sterile  gauze  dressing,  held  with  adhesive  plaster,  is  applied,  and 
outside  of  this  a  swathe,  if  in  the  dorsal,  or  a  bandage,  if  in  the  cervical, 
region. 

The  first  dressing  is  done  at  the  end  of  forty-eight  hours  and  the 
wick  omitted.     After  this  the  wound  is  inspected  and   the  dressing 

^  Amer.  Jour.  Orth.  Surg.,  1907-08,  v,  208. 

^  Inaug.  Diss.,  Breslau,  1903;  Cent.  f.  Chir.,  1904,  xxi,  341. 


LAMINECTOMY  599 

changed  at  from  two-  to  four-day  intervals,  depending  upon  the  amount 
of  discharge  from  the  sinus.  The  stitches  are  removed  on  the  fourteenth 
day. 

Where  the  operation  is  done  for  a  tumor  or  some  similar  condition  not 
associated  with  injury,  no  especial  support  for  the  spine  is  necessary. 
The  patient  is  placed  on  an  air-cushion  and  may  be  turned  from  side 
to  side  without  great  difficulty.  At  the  end  of  three  weeks  the  patient 
may  get  up  and  begin  to  move  about. 

On  the  other  hand,  when  the  operation  has  been  performed  after 
a  fracture  of  the  spine,  the  convalescence  is  fraught  with  complications 
and  difficulties.  When  the  fracture  is  in  the  dorsal  or  lumbar  region, 
the  spine  is  immobilized  by  sand-bags  placed  under  the  back  and  the 
patient  is  placed  on  a  Bradford  frame  (a  gas-pipe  rectangle  supporting 
a  canvas  hammock).  When  the  cervical  region  is  involved,  extension 
is  emiployed  by  means  of  an  extension  apparatus  like  that  used  for  cer- 
vical caries.  If  the  patient  sur\"ives  this,  immobilization  and  extension 
must  be  employed  for  at  least  six  to  eight  weeks  and  the  patient  is  then 
put  in  a  plaster  or  leather  jacket,  which  is  worn  for  months  or  years. 

These  patients  are  always,  at  least  at  the  outset,  partly  or  completely 
paralyzed  below  the  level  of  the  lesion.  This  necessitates  the  most 
careful  nursing  to  prevent  bed-sores.  The  skin  must  be  rubbed  twice 
a  day  with  50  per  cent,  alcohol  and  powdered  with  talcum  or  starch  and 
zinc  dusting-powder,  especially  in  the  folds.  The  subcutaneous  bony 
processes  must  be  protected  from  pressure  by  inflated  rubber  rings. 
If  there  is  incontinence  of  sphincters,  a  large  oakum  pad  must  be  placed 
beneath  the  buttocks,  frequently  changed,  and  the  skin  in  the  region 
carefully  dried  and  powdered.  In  spite  of  the  necessity  for  immobiliza- 
tion the  patient  must  be  turned  from  side  to  side,  still  supporting  the 
spine  with  sand-bags,  however,  to  avoid  continuous  pressure  on  any 
one  spot  and  hypostatic  congestion  of  the  lungs.  If  the  skin  becomes 
broken,  the  spot  must  be  protected  by  an  inflated  ring  and  the  alcohol 
and  powdering  process  repeated  with  increased  frequency. 

Retention  of  urine  is  the  rule,  but  the  patient  should  be  catheter- 
ized.  Catheterization  almost  inevitably  results  in  cystitis,  but  it  is 
delayed  in  proportion  to  the  cleanliness  exercised  in  the  use  of  the 
catheter. 

jMassage  and  electricity  to  the  paralyzed  extremities  will  aid  in 
restoration  of  function  if  there  is  to  be  any,  and  later  a  brace  may  be 
devised,  if  necessary,  to  allow  the  patient  to  walk.  The  diet  should 
be  chiefly  liquid  for  the  first  few  days,  and  if  the  patient  survives  and 
gains  in  strength,  a  fairly  extensive  diet  may  be  allowed  later,  even 


600  OPERATIONS    ON   BONES   AND   JOINTS 

small  amounts  of  meat  and  vegetables  being  given  after  the  first  week. 
The  bowels  are  moved  by  enemas  if  necessary. 

Complications  and  Sequelae. — (i)  Leakage  of  cerebrospinal 
fluid  after  operation  is  controlled  by  a  tight  pressure  bandage  on  the 
wound, 

(2)  Meningitis  is  one  of  the  most  common  complications  and  is 
almost  necessarily  fatal. 

(3)  Bed-sores  should  be  treated  by  relief  of  pressure,  using  an  in- 
flated ring,  and  the  daily  application  of  a  10  per  cent,  iodoform  in  lanolin 
ointment.  Bed-sores  may  be  the  result  of  trophic  disturbances  as  well 
as  pressure,  and  under  such  circumstances  result  fatally  with  great 
rapidity.     (See  Chap.  XXXII.) 

(4)  General  infection,  pneumonia,  bladder  infection  extending  to 
kidneys,  and  shock  are  common  causes  of  death  after  fractures  of  the 
spine. 

(5)  Cystitis,  when  it  occurs,  must  be  treated  by  constant  drainage 
and  daily  bladder  irrigations  with  4  per  cent,  boric  acid  or  i :  5000  silver 
nitrate  solution.     Urinary  antiseptics  are  given  by  mouth. 


CHAPTER  LII 
THERAPEUTIC  IMMUNIZATION  AND  VACCINE  THERAPY 

By  George  P.  Sanborn,  M.D.,  Boston 

Sometime  Assistant  in  the  Laboratory  of  Professor  Sir  A.  E.  Wright,  at  St.  Mary's  Hospital,  London 


Principles  of  Immunization 

The  science  and  art  of  immunization  as  applied  to  surgery  has 
for  its  purpose  tlie  direction  of  the  normal  human  mechanism  for  the 
combating  of  infective  processes  in  the  attempt  to  overcome  surgical 
infections.  It  is  intended  to  assist,  and  not  to  supplant,  the  ordinary 
approved  surgical  methods,  such  as  incision  and  drainage  and  the  em- 
ployment of  asepsis.  It  is  intended  not  to  emphasize  the  importance 
of  any  one  measure,  be  it  surgery  or  bacterial  vaccine,  but  to  give  to 
each  its  proper  place  in  so  far  as  it  contributes  to  the  process  of  im- 
munization. 

Surgery  directs  itself  in  the  treatment  of  localized  infectious  proc- 
esses to  extirpation  of  the  diseased  focus,  or  to  incision  and  free  drainage 
of  pus,  and  has  followed  up  these  measures  to  a  considerable  extent 
by  attempts  to  destroy  the  causal  agents — the  bacteria — ^by  means  of 
antiseptics,  as  applications  and  as  irrigations  of  wounds,  cavities,  and 
sinuses.  If  success  has  crowned  the  effort  to  complete  extirpation, 
if  drainage  is  effective,  and  infected  material  is  thoroughly  discharged, 
cure  is  to  be  expected.  There  are  exceptions,  however,  to  this  rule, 
notably  in  the  case  of  furunculosis.  Here,  in  spite  of  proper  drainage 
and  attempts  to  maintain  the  condition  of  the  skin  as  sterile  as  possible, 
new  furuncles  will  commonly  develop  in  different  parts  of  the  body. 

Extirpation. — The  frequency  with  which  tuberculous  nodes  de- 
velop beneath  the  scar,  following  an  operation  for  extirpation,  indicates 
the  difiSculty  of  radical  and  complete  excision  of  infected  tissue.  Where 
bone  is  the  seat  of  tuberculous  or  other  infectious  disease,  the  persistence 
of  discharging  sinuses  for  months  and  even  years  indicates  that  surgery 
has  not  been  sufficient.  In  tuberculous  infections  of  the  genito-urinary 
tract,  where  the  kidney  or  the  testicles  are  involved,  it  is  extremely 

601 


602  THERAPEUTIC   IMMUNIZATION  AND   VACCINE   THERAPY 

uncommon  not  to  have  other  focus  or  foci  in  other  portions  of  this 
system  of  organs.  Where  the  testicles  are  the  prominent  seats  of  infec- 
tion and  are  removed,  it  is  commonly  to  be  found  that  the  bladder, 
prostate,  spermatic  cord,  etc.,  may  be  singly  or  severally  concomitant 
seats  of  the  same  diseased  process.  Though  in  some  cases  the  removal 
of  a  tuberculous  kidney  will  result  in  marked  improvement  in  tuber- 
culous cystitis,  or  the  removal  of  a  testicle  will  be  followed  by  apparent 
freedom  from  other  active  involvement,  it  is  most  common  for  equally 
serious  conditions  to  exist  or  to  develop  elsewhere.  In  attempting  to 
extirpate,  therefore,  we  are  confronted  with  the  difficulty  of  complete 
extirpation,  and  where  several  organs  are  involved  which  cannot  be 
extirpated,  we  are  confronted  with  the  impossibility  of  eradicating 
more  than  perhaps  the  most  prominent  focus  of  disease. 

Drainagfe. — Upon  the  induction  and  perpetuation  of  free  drainage 
depends  the  success  in  the  treatment  of  localized  infections  of  the  pyo- 
genic type,  and  a  considerable  percentage  of  the  failures  to  produce 
conditions  suitable  for  rapid  healing  are  due  to  the  use  of  methods  w^hich 
interfere  with,  rather  than  further,  proper  drainage  of  infected  material. 

Antiseptics. — The  attempt  to  destroy  all  the  bacteria  in  the  focus 
by  means  of  antiseptics  is  futile.  That  it  has  been  a  failure  is  attested 
by  the  fact  that  for  the  last  few  years  the  practice  has  gradually  gravi- 
tated toward  the  use  of  extremely  mild  antiseptics  for  surgical  dressings, 
soaks,  and  irrigation,  such  as  weak  boric  acid,  chlorinated  soda,  or 
normal  salt  solution.  If  the  antiseptic  solution  is  sufficiently  strong  to 
kill  the  bacteria,  it  will  be  equally  efficient  in  its  injury  to  tissue-cells. 
Further,  excepting  in  unusual  cases,  the  antiseptic  application  cannot 
be  expected  to  come  into  contact  with  all  the  bacteria.  Those  which 
have  escaped  its  action  will  find  a  good  culture-medium  for  further 
growth  in  the  cells  that  have  been  injured,  and  in  the  exudation  which 
the  irritation  of  the  antiseptic  will  have  produced.  Gauze  drains  have 
their  part  in  making  matters  worse,  when  they  obstruct  the  discharge 
and  lead  to  the  accumulation  of  pus  and  bacteria  under  some  slight 
pressure. 

The  persistence  of  infectious  disease  in  spite  of  surgical  effort  attests 
in  such  cases  surgical  failure.  Extirpation  that  does  not  completely 
extirpate,  drainage  that  does  not  effectually  drain,  and  impossible 
methods  of  destroying  bacteria  in  the  infected  foci,  should  not  be  ex- 
pected to  lead  to  any  but  a  considerable  percentage  of  failure,  and 
suggests  the  adA'antage  of  methods  that  will  be  more  effectual  in  the 
accomplishment  of  cure  than  those  in  present  use  in  the  treatment  of 
localized  infections. 


PHYSIOLOGIC   IMMUNIZATION  603 

The  fact  of  spontaneous  recovery  from  infectious  disease  indicates 
that  the  body  has  the  power  to  immunize  itself  against  the  bacteria  and 
the  bacterial  products  which  are  its  cause.  The  so-called  "expectant 
treatment"  attests  our  confidence  in  such  immunizing  ability,  or  physio- 
logic immunizing  mechanism,  as  it  were,  as  does  the  present  method 
in  the  treatment  of  pulmonary  tuberculosis,  of  placing  the  patient 
under  the  best  conditions  of  hygiene,  and  trusting  for  the  cure  to  the 
inherent  power  of  the  body;  again  in  diphtheria,  when  antitoxin  is  in- 
jected for  the  purpose  of  accomplishing  what  the  patient  might  not 
successfully  accomplish  if  left  unaided.  Not  only  the  fact  of  recovery 
from  infectious  disease,  but  future,  lessened  susceptibility  to  infection 
of  the  same  nature,  indicates  that  the  body  not  only  develops  the 
power  of  destroying  the  bacteria,  but  retains  that  power  for  a  certain 
time  in  sufficient  degree  to  prevent  further  infection. 

Through  laboratory  research  much  has  been  learned  as  to  the  manner 
in  which  the  body  protects  itself  against  bacterial  invasion,  and  rids 
itself  of  infecting  bacteria  when  they  have  overcome  the  normal  protec- 
tive mechanism,  and  have  found  lodgment  and  produced  disease. 

When  horses  are  treated  with  increasing  doses  of  the  toxin  of  diph- 
theria bacillus  they  become  immune  to  excessive  doses  of  this  poison, 
while  if  such  excessive  dose  had  been  given  at  first,  the  animal  would 
have  succumbed.  We  find  reason  for  this  immunity  in  the  content  of 
the  horses'  blood  in  antitoxin,  which  the  normal  horse  does  not  possess, 
and  which  is  found  to  neutralize  the  toxin  of  diphtheria  if  the  toxin 
and  the  antitoxin-bearing  serum  are  mixed  in  proper  proportions.  The 
serum  of  such  an  immunized  animal  when  injected  into  a  patient  suffer- 
ing from  diphtheria  has  resulted  in  practice  in  a  large  diminution  in  the 
mortality  from  this  disease. 

Ehrlich,  by  inoculating  ricin  into  laboratory  animals,  showed  that 
the  blood-serum  of  the  animal  inoculated  contained  a  substance  which 
entered  into  combination  with  the  ricin  and  rendered  it  inert.  When 
snake  venom  is  injected  into  an  animal,  beginning  with  very  small  doses, 
there  is  developed  in  the  blood  a  substance  which  is  found  to  neutralize 
and  render  ineffective  snake  venom,  if  proper  proportion  of  each  are 
mixed.  The  animal  inoculated  may  be  rendered  immune  to  extremely 
large  doses  of  the  snake  venom:  These  substances,  developed  as  a  result 
of  inoculation  with  specific  toxins,  are  a  content  of  the  blood-serum 
and  are  specific;  that  is,  they  combine  with  and  neutralize  only  the 
particular  toxin  at  the  stimulus  of  which  they  were  developed. 

The  immunity  thus  developed  in  response  to  the  stimulus  of  these 
poisons  is  termed  active.     The  serum  of  these  animals,  in  that  it  com- 


604  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

bines  with  and  renders  inert  the  corresponding  toxin,  is  termed  an 
antitoxic  serum.  Such  a  serum  injected  into  an  animal  in  proper  amount 
will  produce  a  temporary  immunity  to  the  corresponding  toxin,  and 
to  a  certain  degree  immunity  to  the  infection  that  produces  it.  This 
type  of  immunity,  which  is  conferred  by  the  injection  of  antitoxin,  is 
termed  passive.  Diphtheria  antitoxin,  therefore,  induces  a  passive 
immunity,  in  that  the  body  cells  of  the  treated  individual  have  no  part 
in  the  production  of  the  antitoxin. 

The  power  of  the  animal  body  to  produce  substances  which  shall 
protect  it  against  poisons,  as  above  indicated,  is  not  limited  to  the  forma- 
tion of  antitoxins  against  poisons  or  toxins.  It  is  found  also  that  in 
response  to  infection  with  living  bacteria,  or  to  the  inoculation  of  killed 
pathogenic  bacteria,  there  is  a  response  which  may  not  only  direct 
itself  to  the  neutralization  of  the  poisons  which  they  contain,  excrete,  or 
secrete,  but  also  which  may  direct  itself  to  the  actual  destruction  of  the 
invading  bacteria.  These  new  antibacterial  substances,  to  be  found 
in  the  blood  subsequent  to  infection  or  to  inoculation  with  certain  killed 
bacteria,  are  for  the  most  part  directed  only  against  those  bacteria  and 
their  poisons  which  constitute  the  actual  stimulus  to  the  formation  of 
these  antibacterial  substances. 

So  far  it  has  been  impossible  to  isolate  these  newly  formed  protec- 
tive antitropins,  as  they  are  termed  by  Wright,  and  they  are  only  dif- 
ferentiated by  the  different  manner  in  which  they  severally  exert  their 
power  against  the  bacteria,  in  response  to  infection  with  which  they 
have  been  produced,  and  by  their  behavior  when  subjected  to  certain 
laboratory  tests.  In  response  to  actual  infection  with  certain  organ- 
isms, such  as  typhoid,  cholera,  and  some  others,  or  to  inoculation  with 
killed  cultures  of  the  same  organisms,  the  blood-serum  is  found  to  have 
acquired  the  power  of  agglutinating,  killing,  and  dissolving  these  organ- 
isms when  brought  into  contact  with  them  in  vitro,  even  when  the  serum 
is  highly  diluted,  and  these  substances  are  named,  according  to  their 
effect,  agglutinins,  bactericidins,  and  hacteriolysins.  They  are  not  to  be 
demonstrated  in  an  effective  amount  with  serum  of  normal  indi^iduals. 
In  the  common  infectious  processes,  due  to  the  staphylococcus,  streptococ- 
cus, pneumococcus,  and  some  others,  the  blood-serum  itself  has  no  such 
inherent  destructive  action  so  far  as  is  now  known,  and  hence  these 
substances  do  not  seriously  enter  into  consideration  as  means  of  pro- 
tection against  these  organisms.  In  the  bodily  reaction  against  typhoid, 
colon,  cholera,  and  some  other  infections  the  role  of  these  antibacterial 
substances  appears  to  be  an  important  one. 

There  is,  however,  beyond  these  distinctly  antibacterial  substances, 


'  THE  ROLE   OF   OPSONINS  '  605 

a  fourth  factor,  the , opsonin,  which,  working  in  conjunction  with  the 
leukocytes  and  other  phagocytic  cells,  accomplishes  the  destruction  of 
bacteria.  The  opsonin  so  affects  the  bacteria  by  combination  with 
their  cell  protoplasm  that  the  phagocytic  cells  are  enabled  to  ingest 
those  microorganisms  with  which  they  come  into  contact.  Whereas, 
the  first  three  antibacterial  substances,  or  bacteriotropins,  are  produced 
by  the  body  only  in  response  to  a  limited  number  of  infections,  the 
opsonin  and  the  phagocytes  in  conjunction  exert  their  destructive  effect 
against  all  pathogenic  bacteria.  As  is  well  known,  Metchnikoff,  as 
far  back  as  1883,  attributed  recovery  from  infectious  diseases,  decreased 
susceptibility  to  any  infectious  disease  from  which  an  individual  has 
recently  recovered,  and  in  certain  cases  natural  immunity,  to  the  ability 
of  the  leukocytes  to  ingest  and  kill  bacteria.  He  did  not,  however, 
recognize  that  the  serum  had  an  effect  upon  bacteria  to  prepare  them 
for  phagocytosis,  but  supposed  that  if  the  serum  had  any  effect  it  was 
exerted  in  the  way  of  stimulating  the  leukocytes  to  greater  phagocytic 
activity.  When,  in  1895,  Denys  and  Le  Clef  produced  immunity  to  the 
streptococcus,  by  injecting  rabbits  wuth  increasing  numbers  of  these 
organisms  over  a  considerable  period,  they  found  that  such  animals, 
when  injected  with  living  cultures  of  the  streptococcus  of  erysipelas, 
did  not  develop  the  disease.  It  was  their  belief  that  this  power  to  resist 
the  same  amount  of  living  bacterial  culture  which  killed  rabbits  which 
had  previously  not  been  inoculated  w^as  due  to  the  increased  ability, 
which  they  found  the  leukocytes  had  acquired,  of  ingesting  bacteria. 
They  attributed  this  increase  of  phagocytic  power  to  the  effect  of  some 
newly  acquired  characteristic  of  the  serum,  resulting  from  the  inocula- 
tion which  had  the  effect  of  stimulating  the  leukocytes  to  attack  and 
ingest  the  bacteria. 

The  demonstration  of  the  actual  role  of  opsonin  is  the  result  of  the 
researches  of  Wright  and  Douglas.  They  showed  that  the  leukocytes 
owe  their  ability  to  ingest  bacteria  to  the  presence  in  the  serum  of  a 
substance  whose  function  it  is  to  combine  with  the  bacterial  cell  and 
render  it  palatable  to  the  leukocytes;  that  this  opsonin  does  not  exert 
a  stimulating  action  upon  the  leukocytes  themselves  in  the  process 
of  ingesting  bacteria;  that,  in  the  absence  of  serum,  bacteria  are  not 
ingested  by  leukocytes  excepting  in  a  negligible  degree;  that  opsonin 
is  a  constituent  of  normal  serum,  and  in  much  larger  and  more  effec- 
tive amount  in  the  serum  of  animals  that  are  made  immune  to  some 
microorganism  by  protective  inoculation;  that,  in  the  human  being, 
upon  recovery  from  certain  infectious  diseases,  increased  opsonic  power 
is    demonstrable;    that   opsonin    in    normal    blood    is    active    in    pre- 


6o6  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

paring  nearly  all  varieties  of  bacteria  for  phagocytosis;  and  that,  where 
there  is  effective  response  to  any  particular  infection  leading  toward 
recovery,  the  increase  in  the  phagocytic  powder  is  directed  only  against 
the  infecting  organism,  the  efficiency  of  phagocytosis  against  other 
organisms  being  approximately  as  found  in  uninfected  individuals. 

In  the  systemic  reaction  against  infection,  therefore,  the  opsonin  is 
an  important  factor,  because  upon  it  depends  the  ability  of  the  body  to 
offer  effective  phagocytic  resistance,  because  it  is  directed  against  all 
species  of  pathogenic  organisms,  and  because  in  conjunction  with  the 
leukocytes  it  constitutes  the  first  defense  of  the  immunizing  mechanism 
against  infection.  The  other  means  of  defense  which  the  immunizing 
mechanism  offers,  represented  by  the  substances  above  referred  to, 
the  bactericidins,  bacteriolysins,  and  agglutinins,  are  only  called  into 
being  some  time  after  infection  has  taken  place  as  a  secondary  defense, 
and  then  only  against  a  limited  number  of  pathogenic  microorganisms. 
In  the  common  infections  due  to  staphylococcus,  streptococcus,  pneu- 
mococcus,  and  possibly  the  tubercle  bacillus,  the  opsonin  not  only 
appears  to  supply  the  means  of  first  defense,  but  would  also  appear 
to  exert  a  predominating  influence  in  immunity  from  these  infections, 
because,  so  far  as  is  known,  excepting  for  the  agglutinins  developed  in 
the  case  of  tubercle,  no  other  antibacterial  substances  have  been  de- 
monstrated in  effective  amount.  Nuttall  found  that  the  blood  exerted 
no  bactericidal  action  upon  the  staphylococcus,  and  this  was  con- 
firmed' by  Wright.  Denys  found  that  virulent  streptococci  were  not 
ingested  by  rabbit  white  corpuscles  when  in  contact  with  normal  rabbit 
serum,  but  when  in  contact  with  the  serum  of  a  rabbit  immunized 
against  the  streptococcus,  the  leukocytes  ingested  the  bacteria.  The 
serum  from  the  immunized  rabbits  had  no  bactericidal  effect  upon  the 
streptococci.  When  the  leukocytes  were  added,  the  bacteria  were 
ingested  and  destroyed.  Further  evidence  of  the  importance  of  op- 
sonin in  these  infections  is  that  during  acute  stages  of  pneumococcic, 
streptococcic,  staphylococcic,  tuberculous,  and  other  infections  the 
phagocytic  power  has  been  found  uniformly  below  normal,  but  when 
an  immunizing  response  is  heralded  by  a  fall  in  temperature  and  recovery, 
the  phagocytic  power  is  found  to  rise  considerably  above  normal.  Hek- 
toen^  attributes  to  phagocytic  immunity  the  predominating  effect  in  the 
destruction  of  streptococcus,  pneumococcus,  staphylococcus,  and  some 
others,  and  possibly  the  tubercle  bacillus. 

Opsonin  and  other  bacteriotropins  probably  originate  from  the 
connective-tissue  cells  as  a  result  of  their  stimulation  by  the  specific 

*  Western  Medical  Review,  February,  1908. 


THE   FORMATION    OF   OPSONINS  607 

poisons,  inducing  them  to  react  in  the  fornlation  of  these  protective 
substances.  It  is  reasonable  to  look  upon  these  protective  substances 
as  free  receptors  which  are  able  to  act  in  their  destructive  manner  upon 
the  bacterial  cells.  In  favor  of  local  production  of  opsonins,  that  is,  at 
the  point  of  inoculation  of  killed  bacteria,  there  is  considerable  evidence. 
Theoretic  conception  of  the  formation  and  the  manner  of  action  of  opsonins 


CONNtCTlve 
Tissue  CELLS 


oPsoNizeo 

READY  roR 
PHAGOCYTOSIS 


BACTtRlOTROPINS 


Fig.  203. — Chart  Illustrating  the  Probable  Mode  of  Action  of  Vaccine  When  Injected. 

and  other  antibacterial  substances,  developed  as  a  result  of  inoculation 
of  killed  cultures  of  vaccine,  is  well  shown  in  Fig.  203.  It  will  be  seen 
that  the  bacterial  vaccine  injected  locally  is  supposed  to  disintegrate 
in  the  subcutaneous  tissue,  setting  free  its  specific  poisons,  which  act 
upon  the  body  cells  and  stimulate  them  to  produce  corresponding 
antisubstances  or  antitropins,  according  to  the  character  of  the  micro- 


FOCU&        (.-'^^X.-r"  /CN    CONNECTIVE 


\. 


TISSUE    CELLS. 


1—^  BACTeRlQTROP\NS- 


Fig.  204. — Chart  Illustrating  the  Effect  of  Manipulating  an  Infected  Focus,  in  Disseminating 
Bacteria,  and  the  Probable  Mode  of  Action  of  this  Living  Vaccine. 

organism  injected.  These  new  substances,  opsonins,  bactericidins, 
agglutinins,  etc.,  as  the  case  may  be,  are  sent  forth  into  the  blood-stream, 
and  conveyed  to  all  parts,  of  the  body  to  the  foci  of  infection  and  com- 
bine with  the  bacteria  in  a  destructive  manner.  In  the  case  of  opsonin, 
a  combination  is  effected  with  the  bacterial  cell  which  renders  it  subject 
to  phagocytosis. 

Wright  not   only  demonstrated  the  role  of  opsonin  as  a  factor  of 


6o8  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

predominating  importance  in  the  protective  mechanism  of  the  body, 
but  also  developed  the  method  of  Leishman,  so  that  it  could  be 
used  to  measure,  more  or  less  accurately,  the  effective  opsonic  power 
of  the  blood  in  many  infectious  processes.  He  compared  the  phagocytic 
abihty  of  the  blood  to  be  tested  with  that  of  the  blood  of  uninfected 
individuals.  In  other  Avords,  he  measured  and  compared  the  effective 
opsonic  power  of  an  uninfected  individual  and  the  power  in  the  case  of 
any  individual  suffering  from  bacterial  disease,  both  against  the  infecting 
microorganism.  The  result  of  this  comparison,  that  is,  the  ratio  of  the 
two,  he  termed  the  opsonic  index. 

Wright's  method  for  this  determination  is  briefly  as  follows:  Into 
a  capillary  pipet,  as  shown  (Fig.  205),  with  a  rubber  teat  afiflxed,  are 


A 


lA. 


rORPUSCLES         -t-        EMULSION  OF                          .             NOtSMAL,^      .M  i-CUCOCYTES  HAVE  .aO0__  2.(oF  B/fcTEHlA 

'  TUBERCl-E  BAC1LI.1  ^  3  E  R  L)  n      !«  QtST  ED    ZOO  BACTER\A  100         *•  ^TER  LEUCOCn 


LOKf-Uitl-C  TUBERCLE    BACILLI       ^         SERUM         ,N(i£STEQ    IbO  6ACTERIA         100 


1^0^1.6 


MV-KUnBtR 


cocm 


A  BE  iFHAfi.  inde;!; 

FKA^  INDEX 
,   rv  .-  V      —       PAT  I  ENT     _       l-fa  —  «rt 

OPSONIC     IISDEX     -      NOHMAU      ~    TIT        "       '^^ 
PHAGi  index 

Fig.  205. — Essentials  and  Method  for  Detersiixation  of  the  Tuberculo-opsokic  Index. 

drawD  equal  volumes  of  the  blood-serum  of  a  normal  individual,  of 
blood-corpuscles  which  haA'e  been  washed  free  from  serum,  and  of  an 
emulsion  of  bacteria  against  which  it  is  desired  to  determine  the  opsonic 
power  of  the  patient's  serum.  Each  of  these  three  volumes  is  drawn 
into  the  pipet  separated  by  an  air-bubble,  and  then  expressed  upon 
a  slide,  mixed  thoroughly,  drawn  into  the .  pipet  again,  the  pipet 
sealed  in  a  flame,  and  incubated  for  fifteen  minutes  at  37^°  C.  A 
similar  procedure  is  carried  .out,  using  the  same  corpuscles  and  the 
same  emulsion  of  bacteria,  but  the  patient's  serum  instead  of  the  normal, 
and  incubation  is  carried  out  for  the  same  length  of  time.  These 
pipets  are  removed  at  the  end  of  incubation  period,  the  small  end 
broken  off,  and  the  contents  expressed  upon  a  clean  slide,  mixed  thor- 


THE    OPSONIC    INDEX  609 

oughly,  a  small  drop  of  this  mixture  placed  upon  a  clean  slide,  and 
a  smear  made.  Each  of  the  mixtures  is  treated  in  this  way.  If  the 
smears  are  then  stained  and  the  leukocytes  scrutinized,  it  will  be  found 
that  they  have  ingested  numbers  of  bacteria  in  each  of  the  specimens. 
All  the  bacteria  contained  in  loo  leukocytes  in  the  case  of  each  slide 
are  counted,  and  the  average  number  ingested  by  each  leukocyte  is 
calculated.  This  number  is  termed  the  phagocytic  index.  The  opsonic 
index  is  determined  by  dividing  the  average  number  of  bacteria  per 
leukocyte  which  have  been  ingested  in  the  experiment  with  the  patient's 
serum,  by  the  average  number  ingested  in  the  experiment  when  the 
normal  blood-serum  is  used.  The  resulting  figure  represents  the  ratio 
between  the  phagocytic  power  of  the  patient's  and  the  normal  serum, 
the  normal  serum  being  considered  as  unity.  An  opsonic  index,  there- 
fore, of  1.5  indicates  that  the  effective  phagocytic  power  or  opsonic 
power  of  the  patient's  blood  is  one  and  a  half  times  that  of  the  normal 
individual.  If  the  result  of  the  division  is  0.5,  it  shows  that  the  effective 
phagocytic  or  opsonic  power  of  the  patient's  serum  is  just  half  that  of 
the  normal  individual.  In  order  to  obtain  an  average  normal  serum 
it  is  the  custom  to  mix  the  blood-serum  of  several  individuals  who  are 
known  not  to  be  infected  with  the  particular  organism  in  question. 

The  beginnings  of  vaccine  therapy,  as  Wright  has  conceived  and 
developed  it,  may  perhaps  be  attributed  to  a  suggestion  of  Pfeiffer,  who, 
in  conversation  with  Wright,  stated  that  he  had  obtained  in  man  a 
specific  serum  agglutination  reaction  subsequent  to  the  injection  of  a 
heated,  killed,  typhoid  culture.^  In  experimenting  along  this  line, 
Wright  found  that,  as  the  result  of  the  injection  of  a  killed  typhoid 
culture  into  human  beings,  the  bactericidal  power  of  the  blood  was  in- 
creased by  a  single  inoculation,  sometimes  a  thousand-fold;  that  there 
was  also  to  be  measured  a  high  agglutinating  power,  a  high  opsonic 
power,  and,  from  clinical  observation,  it  was  suggested  that  a  certain 
degree  of  antitoxic  power  was  also  developed,  all  directed  specifically 
against  the  typhoid  bacillus  and  its  toxic  products.  The  injection  of 
killed  cultures  thus  resulted  in  the  elaboration  of  the  same  specific  anti- 
baicterial  or  typhotropic  substances  to  be  found  in  the  indiA'idual  infected 
with  and  recovering  from  the  disease.  This  suggested  the  employment 
of  heated  cultures  to  immunize  against  typhoid  individuals  exposed 
to  the  disease  by  artificially  inducing  in  the  body  the  elaboration  of  these 
protective  substances. 

Wright  put  into  extensive  practice  immunization  against  typhoid 
along  these  lines  in  the  British  army  in  South  Africa.     The  results  have 

^  Wright,  Antityphoid  Inoculation,  Constable,  London,  1904. 
39 


6lO  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

fulfilled  expectations.  Mortality  and  incidence  of  the  disease  among 
those  inoculated  were  each  cut  down  one-half,  when  compared  with  the 
mortality  and  incidence  in  an  uninoculated  group.  It  was  found  that 
the  blood-serum  of  the  inoculated  cases  showed  the  characteristic 
presence  of  specific  antibacterial  substances  against  typhoid.  Thus, 
by  directing  the  immunizing  mechanism  in  an  appropriate  manner,  it 
was  made  to  produce  a  defense  of  exactly  the  same  nature  that  it  elabor- 
ates as  a  result  of  actual  infection.  The  killed  cultures  injected  fur- 
nished the  stimulus  to  the  formation  of  protective  substances  in  the 
same  manner  as  living  bacilli  accomplish  this  result  in  the  actual  disease. 
It  should  be  stated  here  that  it  is  probable  that  the  poison  of  typhoid 
bacillus,  staphylococcus,  streptococcus,  pneumococcus,  colon,  and,  to 
a  certain  extent,  tubercle  bacillus,  is  bound  up  in  the  cell  protoplasm, 
and  does  not  act  effectively  in  its  specific  toxic  or  antigenic  manner  until 
killed  and  disintegrated,  when  its  specific  antigens  or  toxins  are  set 
free.  It  is  obvious  that  the  stimulation  of  the  mechanism  that  produces 
protective  substances  must  be  chiefly  a  chemical  one,  and  that  intact 
bacteria  could  hardly  be  expected  to  furnish  such  a  stimulus.  We  must, 
therefore,  assume  in  injecting  killed  cultures  for  immunization  purposes 
that  protective  substances  can  only  result  from  a  solution  of  the  bacteria 
injected  in  the-  tissues. 

It  is  different  in  a  case  of  diphtheria  and  tetanus,  in  which  the  patho- 
genic action  is  due  to  a  soluble  toxin  which  they  secrete  or  excrete, 
which  is  diffused  into  the  circulation  from  the  original  focus  of  growth, 
and  exerts  its  pathogenic  action  by  destructive  combination  with  certain 
body  cells  for  which  it  has  affinity.  We  should  expect,  therefore,  that 
recovery  from  these  diseases  would  depend  on  the  ability  of  the  body 
to  produce  an  antitoxin,  and  this  is  actually  the  case.  Antitoxic  im- 
munity probably  is  not  the  only  defense  that  the  body  offers,  but  that 
this  is  the  predominating  factor  in  the  body  defense  the  efficacy  of  anti- 
toxin as  a  curative  agent  in  diphtheria  suggests. 

We  have  considered  the  response  of  the  body  to  infection  by  the 
formation  of  substances  calculated  to  act  in  a  destructive  manner  upon 
the  infecting  bacteria  or  to  neutralize  their  toxins.  We  have  seen  that 
the  same  manner  of  protective  reaction  may  be  produced  by  inoculation 
with  killed  bacteria  or  specific  bacterial  toxin.  To  such  inocula  Wright 
has  given  the  term  "vaccines."  A  vaccine,  according  to  Wright's  defini- 
tion, is  any  chemical  substance  which,  when  introduced  into  the  organ- 
ism, causes  there  an  elaboration  of  protective  substances,  or  induces  in 
the  organism  an  elaboration  of  bacteriotropic  elements. 

A  bacterial  vaccine  is  a  suspension  of  killed  bacteria  in  sterile  0.85 


NEGATIVE    AND    POSITIVE    PHASE  6ll 

salt  solution,  with  sufficient  preservative  added  to  insure  constant 
sterility.  Such  a  vaccine  is  standardized  as  to  the  number  of  separate 
bacteria  which  are  contained  in  a  cubic  centimeter  of  the  solution. 
Vaccine  of  the  tubercle  bacillus,  in  other  words,  tuberculin,  comes  to 
us  in  various  forms  from  the  manufacturers.  It  may  consist  of  a  suspen- 
sion of  the  bacteria,  as  the  Bacillus  Emulsion,  which  is  standardized 
to  contain  5  mg.  of  tubercle  bacilli  for  every  cubic  centimeter.  An- 
other form  is  the  Tuberculin  R,  which  consists  of  comminuted  bodies 
of  the  bacilli  with  a  certain  amount  of  soluble  toxin  extracted.  Tu- 
berculin R,  then,  is  essentially  the  protoplasm  of  the  bacterial  cell 
finely  comminuted  and  suspended  in  salt  solution,  each  cubic  centi- 
meter of  which  is  said  to  contain  approximately  2  mg.  of  solid  bacil- 
lary  substance. 

There  are  various  other  forms  of  tuberculin  which  contain  the 
poisons  excreted  or  secreted  by  the  bacillus  in  its  growth  in  liquid  media. 
Generally  speaking,  then,  a  vaccine  is  composed  either  of  the  bacteria 
themselves  unchanged,  except  in  so  far  as  they  are  affected  by  the  heat 
used  in  killing  them,  or  by  pulverization,  or  is  some  derivative  of  the 
bacterial  cell. 

As  a  result  of  his  study  of  the  production  of  bactericidins  in  the  blood 
of  individuals  subsequent  to  protective  typhoid  inoculation,  Wright  was 
struck  by  the  fact  that  there  was  a  definite  sequence  of  events  in  the 
production  of  bactericidins  in  every  case,  and  that  the  same  sequence 
of  events  is  to  be  observed  in  the  production  of  other  antibacterial  sub- 
stances, particularly  the  agglutinins  and  in  the  opsonins.  The  features 
of  the  bodily  reaction  Wright  gives  as  follows: 

In  every  case  following  inoculation  of  vaccine  there  is  a  negative 
phase,  characterized  by  an  impoverishment  of  the  blood  in  antitropic 
substances.  Associated  with  this  negative  phase  is  a  condition  of  in- 
creased susceptibility  to  bacterial  infection  or  to  the  toxic  effect  of  the 
toxin  used.'  This  negative  phase  coincides  with  the  period  which  may 
be  associated  clinically  with  greater  or  less  constitutional  distress. 

Succeeding  the  negative  phase  is  a  so-called  positive  phase,  charac- 
terized by  flooding  the  circulating  blood  with  newly  formed  antitropic- 
substances.  It  is  presumed  that  this  phase  is  associated  with  a  maximum 
resistance  to  bacterial  invasion  and  minimum  sensibility  to  the  poisonous 
action  of  the  vaccine.  There  next  comes  a  fall  in  the  bacteriotropic 
content,  resulting  in  a  slightly  lower  bacterial  resistance,  but,  compared 
to  the  period  before  inoculation,  the  blood  shows  an  increase  in  its  anti- 
tropic elements.  The  body  at  this  period,  however,  and  subsequently, 
seems  to  possess  a  greater  power  of  response  to  the  same  vaccinating 


6l2  THERAPEUTIC    IMMUNIZATION    AND    VACCINE   THERAPY 

stimulus.  Wright  sees  in  the  negative  phase  a  period  of  stimulation 
of  the  body-cells  by  the  vaccine;  in  the  positive  phase,  a  period  in  which 
active  protective  response  is  heralded  by  marked  increase  in  the  anti- 
tropic  substances,  and  after  the  remission  of  the  stimulus  and  a  slight 
fall  in  the  antibacterial  power,  a  more  or  less  continued  period  of  in- 
creased resistance. 

The  importance  of  this  sequence  of  events,  which  he  has  shown  to 
be  the  case  in  the  production  of  bacteriocidins,  Wright  believed  to  be 
fundamental,  as  a  delineation  of  the  character  of  protective  response 
in  general.  If  this  is  so,  measurements  of  other  protective  substances, 
such  as  antitoxins,  agglutinins,  and  opsonins,  should  follow  a  like  course 
in  their  development.  Ehrlich  and  Brieger,  in  1893,  showed  that  a  cor- 
responding curve  was  obtained  from  measurement  of  the  antitoxic 
content  of  the  blood  subsequent  to  inoculation.  Jorgensen  and  Madsen 
found  that  the  law  of  positive  and  negative  phase  applied  likewise  to  the 
elaboration  of  agglutinins  after  inoculation  in  typhoid  and  cholera. 
By  measuring  the  variation  in  the  phagocytic  power  subsequent  to 
staphylococcic  inoculation  later,  Wright  showed  that  the  same  sequence 
of  negative  and  positive  phase  was  to  be  observed. 

A  recognition  of  the  import  of  this  law  of  negative  and  positive 
phase  in  the  production  of  antibacterial  substances,  which  a  study  of 
the  blood  following  protective  typhoid  inoculation  has  furnished,  sug- 
gested to  him  that  like  methods  of  stimulating  the  protective  mechanism 
of  the  body  in  the  actual  presence  of  chronic  disease,  leading  to  the 
increased  formation  of  specific  antibacterial  substances,  might  be  used. 
In  the  year  igco  he  was  confronted  with  a  case  of  chronic  staphylococcic 
infection  which  had  resisted  all  treatment,  and  he  decided  to  make  use 
of  a  corresponding  staphylococcic  bacterial  vaccine,  with  the  hope  of 
inducing  the  formation  of  increased  antibacterial  power.  In  1902^  he 
published  the  results  of  treatment  of  chronic  staphylococcus  infections, 
and  stated  that  he  found  the  same  sequence  of  negative  and  positive 
phase  in  the  diminution  and  increase  of  the  phagocytic  power  following 
inoculation  as  he  found  in  the  bactericidins  of  antityphoid  inoculation. 

The  ease  with  which  the  variations  in  the  phagocytic  power  could 
be  recorded,  and  the  fact  of  the  predominating  influence  of  phagocytosis 
in  the  common  infections  above  other  factors  in  immunity,  led  him  to 
make  use  of  it  as  a  guide  to  the  injection  of  vaccine.  His  aim  was  to 
inject  the  vaccine  in  such  dosage,  and  with  such  frequency,  that  the 
phagocytic  power  of  the  blood  should  be  maintained  in  an  elevated 
condition  over  as  long  an  interval  as  possible,  and  at  the  same  time  to 

^  Lancet,  March,  igo2. 


OPSONIC   INDEX   IN   HEALTH   AND   DISEASE 


613 


eliminate,  so  far  as  possible,  the  so-called  negative  phase  or  phase  of 
diminished  resistance.  Thus  he  sought  to  produce  in  the  blood  an  in- 
crease in  the  actual  constituents  which  were  responsible  for  recovery, 
and  to  obtain  by  frequent  examination  of  the  blood  for  its  phagocytic 
power,  suggestion  as  to  the  time  for  inoculation  and  the  am.ount  of  the 
inoculation  which  could  be  calculated  upon  to  produce  an  efficient 
response.  The  results  that  have  been  produced  by  means  of  injections 
of  corresponding  vaccines  by  Wright,  and  many  others  since,  have 
confirmed  their  efficacy  in  the  treatment  of  localized  infections  in  certain 
infections  which  are  not  strictly  localized.  Even  in  some  that  are 
generalized  their  use  has  offered  some  considerable  hope  for  future 


■l 

r 

80 

. 

76.7 

ro 

60 

50 

40 

30 

20 

10 

in.  1 

- 

10.7 

!■ 

- 

|i 

.8_ 

L 

L 

r 

■ 

r 

■ 

L 

■ 

H 



_ 

t. 

7 

_ 

_ 

_ 

Fig.  206. — Variation  of  the  Opsonic  Index  in  Normal  Individuals.  Based  on  635  Determinations. 
This  chart  shows  graphically  the  results  of  635  tuberculo-opsonic  index  determinations  on  the  blood  of  a 
number  of  individuals  clinically  uninfected  by  tubercle.  These  individuals  were,  for  the  most  part,  laboratory 
workers  whose  sera  were  constantly  being  used  as  "normals"  in  opsonic  index  determination.  These  observa- 
tions were  collected  by  Fleming  and  reported  in  the  "Practitioner,"  London,  May,  1908,  all  from  the  records 
of  Sir  A.  E.  Wright's  laboratory.  It  will  be  seen  that  76.7  per  cent,  of  the  indices  fell  within  0.9s  to  1.05;  lo.i 
per  cent,  between  0.90  and  0.95;  10.7  per  cent,  between  1.05  and  i.io;  and  2.5  per  cent,  below  0.90  or  above 
i.io.  Hence  it  may  be  concluded  that  the  variation  of  the  tuberculo-opsonic  indices  in  normal  individuals  is 
within  cornparatively  small  limits,  94-i  per  cent,  being  between  0.90  and  i.io. 

success  in  their  application.  The  opsonic  index  merely  measures,  more 
or  less  accurately,  variations  in  the  phagocytic  power  of  the  blood  as 
compared  with  the  normal  individual.  It  is  by  no  means  to  be  taken  as 
a  complete  measure  of  the  immunizing  response  of  the  individual  to 
vaccine,  or  as  a  result  of  infectious  disease,  but  on  account  of  a  cor- 
relation with  an  elevated  opsonic  or  phagocytic  power  with  recovery, 
of  a  subnormal  phagocytic  power  with  stasis  and  retrogression,  it  may 
be  taken  as  an  indicator  of  efficient  response  to  infection  and  inoculation. 
The  study  of  the  phagocytic  power  of  the  blood-stream  in  health 
and  disease  by  means  of  the  opsonic  index  determination  has  furnishec' 
a  large  amount  of  accurate  knowledge  as  to  the  bodily  resistance  against 
infection,  and  this  has  furnished  well-defined  indications  for  the  use 


6l4  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

of  specific  measures  in  the  way  of  vaccines  for  the  control  of  infectious 
processes,  and  of  other  measures  which,  as  adjuncts,  enhance  their 
value. 

The  opsonic  power  of  healthy  indi\iduals  conforms  to  a  certain 
mean,  the  variation  being  slight  in  the  same  indhidual  from  day  to 
day  or  in  different  individuals  compared  to  each  other,  as  against  any 
microorganism  with  which  none  of  them  is  infected. 

Fleming^  has  reported  observations  made  in  Wright's  laboratory 
on  the  opsonic  power  in  individuals  whose  blood  has  been  used  as 
normals  in  the  routine  opsonic  technique  in  Wright's  laboratory.  Be- 
tween 600  and  700  indices  were  determined  upon  these  normal  indi- 
viduals, and  it  -was  found  that  in  97-^  per  cent,  of  the  cases  the  extreme 
variation  was  between  0.90  and  i.io,  but  that  in  only  2^  per  cent,  of 
the  determinations  the  indices  were  either  above  i.io  or  below  0.90. 
In  three-fourths  of  the  cases  there  was  a  variation  between  0.95  and  1.05; 
that  is,  a  range  of  variation  of  o.io. 

Bulloch-  showed  that  the  opsonic  indices  of  34  medical  students 
compared  to  his  own  serum,  which  vras  considered  normal  against  the 
tubercle  bacillus,  showed  extreme  variation  from  0.8  to  1.2.  But  three 
of  these  cases  show^ed  indices  above  i.io  or  below  0.90.  or  about  12  per 
cent.  The  remaining  cases — 31 — or  877  per  cent. — v:eve  between  0.90 
and  I.  The  average  normal  opsonic  index  was  0.965.  The  index 
obtained  in  the  same  way  from  32  healthy  hospital  nurses  showed  a 
variation  betveen  0.80  and  i.io.  Again,  he  found  that  about  87  j-  per 
cent,  fell  between  0.90  and  i.io,  with  the  average  normal  opsonic  index 
as  0.969. 

Urwick,  in  20  cases,  found  about  80  per  cent.  betAveen  0.90  and  i.io.^ 

It  appears,  then,  that  the  opsonic  indices  of  normal  individuals 
practically  all  fall  within  a  certain  definite  range  of  variation.  This 
holds  true  in  other  infectious  processes  quite  as  it  does  in  tuberculosis. 
The  reason  for  this  variation  is  probably  partly  due  to  unavoidable 
error  in  opsonic  technique.  We  see  that  the  extreme  limit  of  variation 
is  0.20  in  from  87  to  97  per  cent,  of  the  cases.  This  furnishes  us  a 
reasonable  basis  for  the  conclusion  that,  if  the  opsonic  technique  is  skil- 
fully carried  out,  as  these  observations  would  suggest,  there  is  no  reason 
why  the  experimental  error  should  be  any  greater  in  the  determination 
of  the  opsonic  indices  of  the  serum  of  infected  individuals  than  it  is 
in  that  of  the  normal. 

^  Practitioner,  London,  May,  1908. 

^  Trans.  Path.  Soc.  London,  1905,  vol.  hi,  part  3 

^  Studies  on  Immunization,  Wright,  p.  145. 


THE    NORMAL    AND    IMMUNE    OPSONIN  615 

"We  ha\'e  seen,  therefore,  that  normal  individuals  have  a  practically 
equal  ability  inA-ested  in  their  phagocytic  mechanism  to  ingest  offending 
bacteria;  that  opsonin  is  a  normal  content  of  the  blood-serum,  and  that 
in  conjunction  with  the  leukocytes  it  constitutes  the  early  and  active 
defense  against  bacteria;  that  it  is  not  specific,  but  is  applied  against 
any  and  all  bacteria  that  gain  entrance  to  the  body.  By  means  of 
opsonic  index  determination,  Wright  has  demonstrated  that  after  infec- 
tion takes  place,  or  subsequent  to  inoculation  of  corresponding  vaccine, 
there  are  certain  characteristic  modifications  in  the  opsonic  power  of 
the  blood.     This  has  been  confirmed  by  many  other  investigators. 

Whatever  the  direction  of  the  variation,  be  it  above  or  below  normal, 
such  variation  is  specific  against  the  microorganism  producing  the 
infection,  or  that  which  has  been  injected  as  vaccine.  If  the  same 
blood-serum  be  tested  against  microorganisms  with  which  the  indi- 
vidual is  not  infected,  its  phagocytic  power  will  be  found  to  be  within 
the  normal  limits.  This  suggests  that  there  may  be  a  difference  between 
the  normal  opsonin  and  that  produced  by  inoculation  or  bacterial  disease. 
As  a  matter  of  fact,  the  opsonin  in  normal  individuals  is  not  quite  the  same 
as  in  those  infected. 

The  action  upon  the  bacteria  is  exactly  the  same,  apparently,  in  its 
effect  in  preparing  them  for  phagocytosis.  The  immune  opsonin  differs 
from  the  normal  in  that  it  is  specific  and  acti^'e  only  against  the  invading 
organism.s,  where  the  normal  opsonin  acts  upon  any  and  all  organ- 
isms. A  second  difference  is  that  a  normal  serum,  heated  to  60°  C. 
for  ten  minutes,  becomes  almost  totally  inelficient  in  opsonizing  bacteria, 
whereas  immune  serum  heated  in  the  same  manner  has  a  residuum  of 
opsonic  power.  What  the  exact  nature  of  this  difference  is  has  not  been 
fully  elucidated,  but,  so  far  as  the  present  discussion  is  concerned,  is 
comparati\'ely  unimportant. 

In  strictly  localized  infections,  no  matter  what  the  type,  it  has  been 
found  that  variation  in  the  range  of  opsonic  index  is  almost  without 
exception  subnormal.  In  the  case  of  strictly  localized  tuberculosis,  the 
findings  are  consistent  with  this  general  rule. 

Bulloch^  reports  the  opsonic  indices  in  150  cases  of  lupus.  Com- 
pared with  the  average  opsonic  index  0.97,  which  he  obtained  in  normal 
people,  the  average  for  the  150  cases  was  0.75.  Of  these  cases,  74.4  per 
cent,  fell  between  0.2  and  0.8,  which  latter  may  be  taken  as  the  lowest 
range  of  the  normal  individual. 

Wright-  reports  the  indices  of  31  cases  of  localized  tuberculosis,  the 

^  Trans.  Path.  Soc.  London,  1905,  Ivl,  part  3. 

^  Proceedings  of  the  Royal  Society,  1906,  Bd.  Ixxvii. 


6l6  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

average  opsonic  index  of  which  was  approximately  0.3,  with  extreme 
variation  from  0.13  to  0.88. 

Lincoln  ^  reports  that  40  cases  of  localized  tuberculosis  had  an 
average  opsonic  index  of  0.68,  with  a  range  of  0.3  to  0.9. 

Wright  reports  20  cases  of  staphylococcic  infection,  including  fur- 
unculosis,  sycosis,  and  acne,  in  which  the  opsonic  index  ranged  from 
0.1  to  0.88,  with  an  average  of  0.63.  Wright^  states  that  the  existence 
of  normal  phagocytic  power  in  a  case  of  staphylococcic  infection  is  rare 
and  extremely  exceptional. 

Passing  on  to  the  condition  of  the  opsonic  power  of  the  blood  in 
acute  infections  or  infections  associated  with  systemic  disturbance  and 
temperature,  we  are  struck  at  -once  by  the  marked  variations.  We  may 
take  as  a  sample  of  such  condition  a  case  of  pulmonary  tuberculosis 
or  other  non-localized  tuberculous  condition.  Wright^  reports  opsonic 
indices  upon  the  blood  of  a  child  suffering  from  tuberculous  caries  of 
the  fibula,  associated  with  constitutional  disturbance.  There  were 
seven  indices  determined  at  from  one-  to  nine-day  intervals.  The  ex- 
trem.e  limits  of  variation  were  from  0.98  to  1.73.  It  should  be  noted  that 
on  the  two  days  following  a  scraping  operation  the  index,  which  l^va 
days  before  the  operation  was  0.98,  was  increased  to  1.73.  As  a  note, 
in  explanation •  of  this  elevated  index,  Wright  states:*  ''A  rise  in  the 
opsonic  power  similar  to  this  here  registered  has  been  repeatedly  ob- 
served by  us  in  connection  with  the  stirring  up,  by  surgical  inter- 
ference, of  tuberculous  foci,"  A  case  of  tuberculous  caries  of  spine 
with  constitutional  disturbance  gave  five  indices,  determined  at  from 
one-  to  two-day  intervals,  ranging  from  0.65  to  1.4.  A  case  of  the 
same  kind  gave  three  indices  ranging  from  0.6  to  2.4,  taken  at  one- 
and  two-day  intervals.  Another  case,  in  which  subsequently  diag- 
nosis of  pulmonary  tuberculosis  was  made,"  showed  opsonic  variations 
of  from  0.48  to  1.35,  the  daily  variation  sometimes  being  from  0.5  to  i.i. 
Other  observers  have  confirmed  these  wide  fluctuations  in  the  opsonic 
power  in  pulmonary  tuberculosis  and  tuberculosis  of  the  non-localized 

type- 
Associated   with   various   diseases  which   undermine   the   patient's 
health  we  commonly   find   a  condition  of  furunculosis.     In  recovery 
from  systemic  infections  like  typhoid  it  is  common.     In  cases  of  diabetes 
patients    are    conspicuously    subject    to    staphylococcic    infections.     A 

^  Illinois  Med.  Jour.,  190S,  .\iii. 

^  Studies  in  Immunization,  p.  103. 

^  Proceedings  of  the  Royal  Society,  1906,  vol.  x.xvii. 

''  Studies  in  Immunization,  p.  153. 

5  Itid.,  p.  385. 


BACTERIOTROPIC    POWER    OF    THE    BLOOD  617 

series  of  i6  cases  of  diabetes  mellitus  were  studied  with  reference  to  the 
condition  of  the  opsonic  index,  suspecting  that  a  condition  of  lowered 
opsonic  power  accounted  for  the  susceptibiHty  to  staphjdococcic  infec- 
tion. This  study,  made  by  Da  Costa,  and  reported  in  the  American 
Journal  of  Medical  Sciences,  July,  1907,  p.  57,  showed  that  the  average 
opsonic  index  was  0.62  and  the  range  from  0.34  to  0.72. 

The  term  "strictly  localized  infection"  is  to  be  taken  as  meaning  an 
infection  which  is  unassociated  with  temperature  or  generalized  symp- 
toms. Such  infections  are  tuberculous  bone  disease,  glands,  some 
cases  of  kidney,  lupus,  testicle,  bladder,  etc.,  furunculosis;  infections 
which  have  passed  the  acute  stage  and  have  become  indolent,  and  in 
which  the  local  condition  and  the  lack  of  localized  symptoms  confirm 
the  suspicion  that  the  process  is  walled  off,  and  no  longer  sends  into 
the  circulation  toxic  products  in  sufficient  amount  to  constitute  general 
febrile  or  other  reaction. 

We  have  spoken  of  the  bare  facts  concerning  the  variation  in  the 
phagocytic  power  of  the  blood-stream  in  health  and  disease.  It  wall 
now  be  advantageous  to  consider  certain  facts  dealing  with  the  bacterio- 
tropic  power  of  the  blood -stream  in  its  relation  to  that  existing  in  the 
localized  foci  of  disease,  in  order  that  we  may  glean  some  indication 
as  to  wherein  the  immunizing  mechanism  fails  in  its  effort  to  rid  the  body 
of  infecting  bacteria  and  suggestion  as  to  how-  failure  may  be  averted. 

The  circulating  blood  has  in  itself  practically  all  the  defensive 
forces  of  the  body  in  the  antibacterial  elements  of  the  serum  and  in  the 
phagocytic  cells  which  it  contains.  Against  bacteria  which  chance  to 
enter  the  blood-stream,  the  sum  total  of  antibacterial  elements  is  at 
once  brought  into  destructive  action.  Against  the  bacteria  are  opposed 
the  whole  force  of  the  leukocytes  and  an  unlimited  supply  of  antibacterial 
substances.  Contrasting  with  the  conditions  of  defense  which  the  cir- 
culation offers  with  the  conditions  that  obtain  in  the  tissues,  we  see  a 
striking  difference,  in  that  in  the  tissue  at  the  moment  of  entrance  the 
microorganisms  will  find,  to  antagonize  them,  a  few  phagocytes,  and  such 
protective  substances  as  the  lymph  contains  in  the  immediate  vicinity; 
whereas  the  blood-stream  offers  against  the  bacteria  the  whole  force  of 
the  leukocytes  and  the  entire  concentration  of  the  blood-stream  in  pro- 
tective substances.  It  is  not  to  be  w^ondered  at  that  septicemias  are, 
comparatively  speaking,  rare  occurrences;  that  localized  infections  re- 
main local,  when  extension  is  opposed  by  the  citadel,  as  Wright  terms  it, 
of  the  blood-stream.  Interesting  and  important  in  this  connection  are 
the  experiments  of  Hektocn  and  Carlson.^     In  dogs  immunized  to  goat 

^  Jour.  Amer.  Med.  Assoc,  January  8,  1910,  p.  130. 


6l8  THERAPEUTIC    IMMUNIZATION    AND    VACCINE   THERAPY 

blood  they  found  that  the  lysin,  agglutinin,  and  opsonin  developed 
against  goat  corpuscles  reached  the  highest  concentration  in  the  blood- 
stream; that  the  thoracic  and  neck  lymph  were  much  poorer  in  these 
substances.  The  same  relative  concentration  of  antibodies  seems  to  them 
to  obtain  in  normal  animals. 

We  see  in  the  phagocytes  and  the  opsonin  factors  which  together 
form  the  first  defense  of  the  body  against  any  and  all  bacteria.  We  see 
in  the  reaction  of  inflammation  the  attempt  of  the  protective  mechanism, 
by  inducing  free  streaming  of  fresh  blood  in  and  about  the  infected 
focus,  to  bring  into  contact  with  the  infecting  microorganisms  large 
numbers  of  leukocytes  and  a  continuous  supply  of  antibacterial  sub- 
stances. Such  is  the  import  of  inflammation.  We  may  conceive  prop- 
erly that  infection  is  an  every-day  occurrence,  while  infectious  disease 
is  more  or  less  infrequent  in  the  individual.  It  is  only  in  cases  where  the 
immunizing  mechanism  fails  at  some  point  that  bacteria  gain  foothold 
and  produce  disease.  The  fact  of  infection  is  commonly  accounted  for 
by  assuming  that  the  organisms  owe  their  ability  to  enter  and  grow 
through  their  extreme  \irulence ;  that  too  large  numbers  of  them  gained 
entrance  to  the  body  at  one  time  for  the  effective  defense  which  the  body 
offers  to  prevent  their  growth;  that  they  have  entered  at  points  where 
the  blood-stream  cannot  be  efficiently  increased  or  properly  brought 
into  contact  with  them;  or,  finally,  when  the  blood  itself,  for  one  reason 
or  another,  is  deficient  in  protective  substances. 

We  know  that  when  bacteria  are  brought  into  contact  with  blood- 
serum  in  vitro  in  sufficient  numbers,  the  opsonin  or  other  antibodies  in 
the  serum  enters  into  combination  with  their  cell  protoplasm.  We  assume 
that  the  same  is  the  case  when  a  number  of  bacteria  enter  the  tissues  at 
one  point,  that  is,  the  lymph  at  the  point  of  inoculation  will  lose  certain 
of  its  opsonins  by  absorption,  on  the  basis  of  experimental  evidence. 
Wright  and  Lamb^  showed  that  the  agglutinating  power  of  the  splenic 
pulp  in  typhoid  and  Malta  fever  is  invariably  lower  than  that  in  the 
circulating  blood;  that  the  agglutinating  power  of  the  serum  in  typhoid 
spots  is  less  than  that  of  the  circulating  blood.  Lamb,  referred  to  in 
the  same  article,  also  showed  that  in  spirillum  fever  in  monkeys  the 
splenic  pulp,  in  which  the  spirilla  cultivate  themselves  after  the  crisis, 
had  much  less  bactericidal  and  lytic  effect  than  the  circulating  blood 
of  the  same  animals.  As  to  the  relative  content  in  opsonin  of  infected 
foci,  compared  with  the  blood-stream,  Wright-  has  shown,  in  a  case  of 
alveolar  abscess,  by  determination  of  the  opsonic  power  of  fluid  obtained 

^  Lancet,  December  23,  1898,  pp.  36-44. 
^  Proc.  Roy.  Soc,  1904,  vol.  Ixxiv. 


THEORIES    RELATING    TO    INFECTION  619 

•by  centrifugalizing  the  pus,  that  the  opsonic  power  of  the  patient's 
blood-stream  was  six  times  that  of  the  pus.  Again,  in  the  case  of  a 
patella  abscess  due  to  streptococcus,  the  blood  was  found  to  have  an 
opsonic  power  eleven  times  that  of  the  pus  fluid.  In  the  case  of  localized 
tuberculosis,  he  also  found  that  the  opsonic  power  of  the  blood-stream 
was  over  three  times  that  of  the  pus  from  the  abscess.  Again,  in  tubercu- 
lous peritonitis  the  blood-stream  was  found  to  possess  six  times  the  opsonic 
power  that  the  peritoneal  fluid  possessed.  As  a  control,  to  rule  out  the 
possibility  that  the  lymph  might  normally  be  poor  in  protective  substances 
as  compared  to  the  blood-stream,  Wright  compared  the  phagocytic  power 
of  his  own  serum,  from  an  aseptic  blister,  and  the  serum  from  his  own 
circulating  blood.  He  found  that  they  had  approximately  the  same 
phagocytic  ability.  Blood-supply  to  the  infected  point,  automatically  in- 
creased as  the  first  reaction  of  inflammation,  may  replace  this  depleted 
lymph  with  fresh,  and  in  addition  furnish  sufficient  numbers  of  phago- 
cytes to  ingest  and  destroy  the  bacteria.  Such  would  theoretically  be 
the  course  of  events  in  the  case  of  an  aborted  infection.  Such  a  series 
of  events  is  probably  taking  place  continuously,  and  represents  the 
initial  strife  between  the  bacteria  and  the  protective  mechanism. 

The  fact  of  extreme  virulence  may  apply  to  certain  bacteria,  notably 
the  pneumococcus  and  streptococcus.  It  has  been  shown  by  Rosenow^ 
that  virulent  pneumococci  are  not  acted  upon  by  the  opsonin  in  normal 
serum  in  a  manner  effective  enough  to  render  them  phagocytable.  The 
same  has  been  shown  in  the  case  of  the  streptococcus.  This  phenom- 
enon Rosenow  fields  to  be  due,  in  the  pneumococcus,  to  a  substance 
which  they  contain  when  \drulent,  but  lose  after  growth  on  culture- 
media.  He  was  able  to  extract  this  substance,  and  found  that  avirulent 
pneumococci,  when  exposed  to  the  action  of  this  extract  for  twenty-four 
hours,  became  again  relatively  insusceptible  to  phagocytosis.  It  would 
seem  that  some  virulent  organisms,  then,  possess  a  substance  capable  of 
neutralizing  or  of  resisting  normal  opsonin. 

When  large  numbers  of  bacteria  enter  the  tissue,  it  may  be  assumed 
that  their  action  is  not  only  to  absorb  the  effective  opsonin  in  the  locus, 
but,  by  dissemination  into  the  blood-stream,  combine  with  the  opsonin 
present,  with  a  result  that  the  total  bacteriotropic  pressure  of  the  blood- 
stream is  at  once  lowered.  The  bacteria  left  in  the  locus  may  be  opsoni- 
fied,  but  sufficient  phagocytes  are  not  available  to  destroy  them.  The 
bacteriotropic  power  in  the  locus  is  thus  lessened,  that  of  the  blood- 
stream depleted,  conditions  that  offer  defective  resistance  to  bacterial 
growth.     The  effect  of  such  a  bacterial  invasion  is  to  produce  a  negative 

^  Illinois  Med.  Jour.,  190S,  xiii. 


620  THERAPEUTIC   IMMUNIZATION    AND    VACCINE   THERAPY 

phase,  quite  like  that  produced  by  an  inoculation  of  killed  bacteria  in 
sufficient  numbers. 

If  bacteria  enter  where  blood-supply  is  deficient,  the  opsonin  in  the 
locus  becomes  rapidly  absorbed,  leukocytes  are  not  brought  to  the  scene 
in  sufficient  numbers,  and  growth  takes  place  in  a  medium  of  lowered 
bacteriotropic  power.  Instance  of  infection  due  to  deficient  opsonin 
in  the  general  blood-stream  is  to  be  found  in  diabetes.  In  this  disease 
Da  Costa  has  shown  {loc.  cit.)  that  the  opsonic  power  is  consistently 
subnormal  to  the  staphylococcus.  Hence  the  tendency  to  furuncle, 
carbuncle,  and  eczema. 

After  localized  infection  has  once  started,  the  conditions  favorable 
to  its  continuance  are  furnished  by  circumstances  which  go  to  prevent 
access  to  the  focus  of  infection  of  the  blood-serum  and  the  phagocytic 
cells.  Here,  the  body's  protective  mechanism,  in  its  attempt  to  safe- 
guard the  body  against  systemic  infection,  has  produced  conditions  that 
are  ideal  in  the  furtherance  of  local  chronicity  of  the  infection. 

When,  as  we  may  assume,  in  a  locus  of  infection,  the  toxins  have 
been  produced  in  sufficient  amount  to  destroy  tissue-cells,  and  the 
leukocytes  have  broken  down  to  a  considerable  extent,  we  have  pus  in 
an  abscess  cavity,  surrounded  by  a  wall  of  tissue,  infiltrated,  swollen, 
infected,  and  efficient  in  shutting  off  any  sufficient  circulation  of  lymph 
in  the  infected  tissue.  The  lymph,  in  contact  with  the  bacteria,  loses 
what  antibacterial  power  it  normally  was  possessed  of,  by  combination 
with  them,^  offering  then  no  obstruction  to  further  bacterial  growth. 
In  pyogenic  infections  we  have  further  to  deal  with  a  ferment  derived 
from  broken-down  leukocytes  which  is  tryptic  in  nature  (Opie),  and 
has  the  effect  of  dissolving  connective  tissue,  thus  furthering  extension 
of  the  process.  If  fresh  leukocytes  chance  to  enter  this  abscess  fluid, 
they  will  find  no  opsonin  to  assist  them,  only  bacterial  toxin  to  destroy 
them. 

Wright  has  shown  (loc.  cit.)  that  the  pus  fluid  has  no  power  of  in- 
ducing phagocytosis,  and  that  leukocytes  from  the  pus,  though  apparently 
healthy,  have  lost  their  povrer  to  phagocyte  even  in  the  presence  of 
healthy  serum. 

In  cases  of  brawny  infiltration,  such  as  carbuncle,  there  is  a  blocking 
of  the  tissues  by  fibrinous  exudate,  pus,  bacteria,  and  necrotic  tissue. 
Circulation  of  fresh  lymph  is  impossible;  the  lymph  in  the  infected  tissue 
has  lost  its  opsonic  power,  and  the  bacteria  are  enabled  to  cultivate 
themselves,  safeguarded  from  the  circulating  blood. 

The  effect  of   a   crust  covering  an  ulcer  is  to  obstruct  the  flow  of 

^  Wright,  Proc.  Roy.  Soc,  1904,  vol.  Ixxiv. 


SIGNIFICANCE    OF    A   FOCUS    OF    INFECTION  62 1 

lymph.  The  bacteria  in  the  lower  portions  of  the  crust  absorb  the 
opsonin  in  whatever  lymph  there  may  be,  since  circulation  of  lymph 
can  only  be  provided  for  by  removing  the  crust  and  allowing  a  discharge. 
Thus  conditions  are  favorable  for  bacterial  growth  beneath  the  crust. 

The  same  difficulty,  that  of  insufficient  lymph  circulation,  is  met 
with  in  chronic  infected  sinuses.  The  bacteria  cultivate  themselves  in 
stagnant  lymph,  the  antibacterial  power  of  which  has  been  abstracted 
by  contact  with  the  organisms.  In  the  case  of  an  effusion  in  a  serous 
cavity,  it  is  found  that  the  fluid  is  very  poor  in  opsonin,  and  hence  has 
correspondingly  little  antibacterial  action.  If  the  phagocytes  are  few 
in  such  an  effusion,  as  they  commonly  are,  the  presence  of  opsonin 
would  be  of  little  value.  The  opsonic  power  of  such  fluid,  in  the  case 
of  tubercle,  has  been  shown  to  be  in  one  case  one-sixth  that  of  the  cir- 
culating blood. 

We  have  next  to  consider  the  conditions  of  the  circulating  blood  in 
its  content  of  antibacterial  substances  in  its  relation  to  the  focus  of  infec- 
tion. There  is  to  be  found  a  depletion  of  protective  substances  in  the 
circulating  blood,  as  shown  by  the  opsonic  index,  in  localized  infections. 
We  have  seen  that,  in  order  to  respond  in  the  elaboration  of  protective 
substances,  bacterial  stimulus  in  the  way  of  vaccine  or  bacteria  from 
the  focus  of  infection  is  necessary.  In  the  condition  of  local  indura- 
tion and  swelling  in  certain  infections,  of  walling  off  of  the  focus  in 
certain  others  by  newly  formed  tissue,  the  blood-supply  becomes  so  cut 
off  that  bacteria  may  not  be  taken  up  in  sufficient  numbers  to  constitute 
a  stimulus  to  the  formation  of  specific  antibodies.  We  may  further 
conceive  that  the  blood-stream,  coming  continuously,  but  in  a  re- 
stricted degree,  into  contact  with  the  outskirts  of  the  focus  of  infection, 
loses  gradually  the  opsonin  of  which  it  should  normally  be  possessed. 
Hence  the  low  opsonic  power  in  localized  infectious  processes. 

We  see,  then,  in  the  blood-stream  a  reservoir  of  antibacterial  power; 
in  the- reaction  of  inflammation,  the  endeavor  to  render  the  local  bac- 
teriotropic  pressure,  as  Wright  terms  it,  as  nearly  equivalent  as  possible 
to  that  of  the  circulating  blood.  In  the  development  of  a  focus  of  in- 
fection, we  see  both  success  and  failure  on  the  part  of  the  immunizing 
mechanism:  success  in  the  fact  of  safeguarding  the  body  from  general- 
ized infection,  failure  in  the  fact  of  producing  conditions  locally  which 
favor  persistence  and  chronicity  of  the  original  infected  focus.  In 
other  words,  in  thus  safeguarding  the  body  we  may  conceive  that  the 
protective  mechanism  has  overreached  itself,  as  it  were,  in  that  the 
condition  of  segregation  of  the  focus  of  infection,  which  contributes  to 
this  end,  also  by  interfering  with  the  circulation  prevents  replenishment 


62  2  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

of  the  lymph  in  the  focus  by  lymph  possessing  the  full  bacteriotropic 
pressure  of  the  blood.  Thus,  in  the  stagnant  lymph  the  bacteria  find  a 
culture-medium  which  offers  no  resistance  to  their  growth. 

A  contributory  factor  to  the  chronicity  of  such  a  local  infection  its 
walled-off  condition  is  responsible  for,  in  that  it  does  not  allow  the 
blood  to  take  up  sufficient  bacteria  to  constitute  an  effective  stimulus 
for  the  production  of  protective  substances.  We  know  that  specific 
protective  substances  do  not  appear  in  the  blood  excepting  as  a  result 
of  such  bacterial  stimulus.  If  this  view  is  correct,  we  should  expect 
in  local  infections  a  more  or  less  constant  phagocytic  power  without 
any  fluctuations  suggestive  of  immunizing  response,  and  in  strictly 
localized  infections,  as  we  have  seen,  the  opsonic  index. would  corroborate 
this  view.  And,  again,  the  infected  focus  is  responsible  for  another 
feature  which  is  characteristic  of  such  infections — the  low  opsonic  power. 
It  would  seem  reasonable  to  explain  this  on  the  supposition  that  con- 
tinuous contact  with  the  outskirts  of  the  lesion  has  resulted  in  the  loss 
to  the  circulating  blood  of  a  portion  of  its  opsonin  by  combination  with 
bacteria  and  their  poisons.  When,  in  certain  infections,  such  as  car- 
buncle, erysipelas,  acute  accidental  infections,  or  pulmonary  tuber- 
culosis (certain  cases)  there  is  a  temperature  reaction,  we  must  attribute 
it  to  the  entrance  of  bacteria  or  their  products  into  the  circulation.  If 
this  is  so,  we  should  expect  immunizing  response  similar  to  that  produced 
by  the  inoculation  of  vaccine  in  the  elaboration  of  protective  substances, 
and  it  is  a  fact  that  measurement  of  the  phagocytic  power  of  the  blood- 
stream furnishes  evidence  of  a  succession  of  negative  and  positive  phases 
which  could  only  arise  through  the  presence  of  bacterial  stimulus  in  the 
blood.  Bearing  in  mind  the  reason  for  spontaneous  recovery  lies  in  the 
automatic  response  of  the  protective  mechanism  through  the  bacterial 
stimulus,  it  becomes  evident  that  it  must  be  through  the  agency  of  such 
automatically  sent-out  stimuli  that  the  blood-stream  derives  its  increased 
power  of  destroying  bacteria.  Such  a  stimulus  would  correspond  in 
its  effect  to  the  inoculation  with  vaccine.  It  is  termed  a  spontaneous 
autoinoculation. 

Spontaneous  recovery  we  must  look  upon  as  having  for  its  basis  effec- 
tive autoinoculation.  The  absence  of  immunizing  response  in  localized 
infections,  as  shown  by  the  low  opsonic  power,  indicates  absence  of 
effective  autoinoculation.  In  the  absence  of  stimulus  to  produce  anti- 
bodies we  should  expect  chronicity,  and,  as  we  have  seen,  localized  cases 
which  offer  no  stimulus,  no  spontaneous  autoinoculation,  are  the  chronic 
cases.  Little  is  to  be  hoped  for,  therefore,  in  the  Avay  of  spontaneous 
cure  of  many  of  these  localized  infections. 


AUTOINOCULATION  623 

Turning  to  the  consideration  of  generalized  infections,  we  should 
at  once  have  more  hope  for  spontaneous  cure,  because  at  the  outset 
we  have  certainly  a  sufficient  condition  of  autoinoculation,  which  may 
be  continuous  if  the  bacteria  constantly  cultivate  themselves  in  the 
blood,  or  it  may  vary  in  amount  at  different  times,  depending  upon  the 
frequency  of  the  effective  response  of  the  body  in  producing  sufficient 
antitropins  to  kill  off  most  of  the  bacteria.  The  protective  mechanism 
in  such  cases  must  be  in  a  condition  of  constant  activity.  The  strife 
between  it  and  the  bacteria,  may  be  of  short  or  long  duration,  depending, 
on  the  one  hand,  on  the  ability  of  the  protective  mechanism  to  respond, 
and,  on  the  other,  on  that  of  the  bacteria  to  immunize  themselves  against 
such  opposition  as  the  blood-stream  offers. 

In  febrile  conditions,  as  septicemia,  we  expect  constant  fluctuation 
in  the  opsonic  power,  on  account  of  constant  autoinoculation.  In 
local  infections,  when  temperature  accompanies,  autoinoculation  is  taking 
place.  In  pulmonary  tuberculosis  in  late  febrile  stages,  even  though 
the  patient  is  in  bed,  opsonic  index  determination  registers  often  wide 
variations  in  the  phagocytic  power,  which  can  only  represent  response 
to  autoinoculation.  Febrile  cases  present,  in  fact,  a  succession  of  positive 
and  negative  phase,  in  bacteriotropic  power.  One  of  the  most  im- 
portant contributions  to  knowledge  of  the  physiology  of  immunity 
came  as  a  result  of  an  observation  made  by  Freeman  in  Wright's  clinic, 
London,  October,  1905.^  In  a  case  of  gonorrheal  arthritis  it  was  found 
that,  following  massage  of  an  affected  knee,  the  patient  suffered  con- 
stitutional disturbance  and  aggravation  of  joint  pain  during  the  few 
hours  following  the  massage,  quite  the  same  as  he  had  experienced 
after  inoculation  with  gonococcal  vaccine.  The  induction  of  symptoms 
following  massage  suggested  that  a  negative  phase  had  been  in  some 
way  induced,  and  a  study  was  made  to  determine  this  point.  It  was 
found  that  in  every  case  after  massage  there  followed  a  marked  increase 
in  the  phagocytic  power  of  the  blood,  and,  in  association,  the  joints 
improved  rapidly;  this  was  not  confined  to  the  joint  massaged,  but  to 
all  the  others  affected.  In  the  rise  in  phagocytic  power  following  manipu- 
lation was  recognized  an  immunizing  response,  which  could  be  due  to 
nothing  else  than  an  autoinoculation,  or  setting  free  into  the  tissue  and 
blood  of  gonococci  or  their  products.  That  this  improvement  \a  as  not 
due  to  massage  of  each  joint  was  proved  by  the  fact  that  no  matter  what 
joint  was  massaged,  the  others  partook  of  the  clinical  improvement  that 
went  hand  in  hand  with  the  increase  in  antibacterial  power. 

Autoinoculation. — Autoinoculation  may  be  induced  in  the  case  of 

'  Lancet,  November  2,  1907,  p.  1226. 


624 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


any  focus  of  infection  where  it  is  possible,  by  some  manipulation,  to  stir 
it  up  sufficiently  to  cause  bacteria  to  be  liberated  into  the  blood  or  lymph 


eoMO-                            1                 .,.,._..                 I  "f  ■*« 

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I90S    ocr.  Rov. 

Fig.  207. — Induced  Autoinocexation. 
The  effect  of  massage  of  a  gonorrheal  joint  upon  the  opsonic  content  of  the  blood  (Wright,  Lancet,  November 

2,  1907,  1227). 

Stream  in  sufficient  numbers  to  serve  as  an  effecti\-e  stimulus  to  the  pro- 
duction of  specific  protective  substances. 

The  following  manipulations  or  exercises  may  induce  such  auto- 
inoculation:  Massage  of  a  gland  or  joint,  passive  or  active  motion  of 

a  joint,  surgical  operation,  increase  in  the 
active  blood-supply  to  the  affected  part, 
by  heat  or  other  means.  Bier's  passive 
hyperemia,  walking,  deep  breathing  in 
pulmonary  tuberculosis,  shouting  in 
laryngeal  tuberculosis,  Wright  has  shown, 
by  means  of  opsonic  index-determina- 
tion, to  be  followed  by  immunizing  re- 
sponse registered  by  elevation  of  the 
opsonic  power  of  the  blood.  Se'\'eral 
charts  illustrating  this  important  phe- 
nomenon are  here  shown  (Figs.  207, 
208,  209,  210,  211,  212).  It  will  be 
noted  that  in  all  cases  the  charts  indi- 
cate decided  changes  in  the  opsonic 
power  following  the  different  proce- 
dures, and  thus  register  immunizing  re- 
.sponse.  The  nature  of  autoinoculation 
being  here  indicated,  the  significance  in  its  relation  to  the  workings  of 
the  protective  mechanism  and  its  usefulness  in  diagnosis  will  be  dealt 
with  later. 

The  only  real  success  in  securing    protection   against  and  in  the 


OPSONIC 
INDEX 

20 
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l'4 
f-2 

NORMAL  10 
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AUG. 1906 
Fig.  208. — Induced  Autoinoculation. 
The    variations    in   the   opsonic   power 
resulting  from  auscultation  and  percussion 
in  pulmonary  tuberculosis  (Wright,  Lancet, 
November  2,  1907,  1231). 


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625 


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Fig.  209.- 


N0V.3    4    5    «     7     8    9    10  11  12  13  14 

OPERATION  CURVE  — T.B..SALP1NG1TIS. 

-AuTors'ocuLATiox  AS  Registered  by  the  Opsonic  Index  Following  Operativ; 
IN  A  Case  of  Tuberculous  Salpingitis. 


Procedure 


•quantity  to  be  effective  in  the  production  of  a  state  of  immunity  against 
the  infection  under  which  it  is  struggling.  Familiar  is  the  example  of  pro- 
tection against  small-pox  by  the  production  of  a  mild  disease^cow-pox. 
It  would  seem  here  that,  through  the  stimulus  which  this  mild  disease 
furnishes,  the  cells  of  the  body  have  derived  an  increased  power  and  a 


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Fig.  210. — In-duced  Autoixocui-ation. 
Tuberculous  bone  disease — ankle.     The  effect  of  walking  (Wright,  Lancet,  November  2,  1907,  1229).- 

more  or  less  permanent  power  to  resist  infection  of  small-pox.  Here, 
then,  has  been  made  use  of  the  body's  own  methods  of  protection  against 
disease. 

Again,  in  protection  against  typhoid  the  use  of  typhoid  vaccine  in- 
duces the  protective  mechanism  to  fortify  the  blood  with  elements  that 

40 


626 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


are  calculated  to  destroy  typhoid  bacilli  when  they  enter  the  body;, 
quite  the  same  elements  appear  to  be  responsible  for  recovery  from  the 
disease.  The  same  may  be  said  of  the  antiplague  inoculation  of  Haff- 
kine. 

A  good  example  of  success  in  following  nature's  lines  of  treatment 
in  the  cure  of  disease  is  that  obtained  in  the  treatment  of  diphtheria  by 


JNDEX 

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1306    JUNE  JULf 

Fig.  211. — Induced  Autoinocdlation  dj  Tuberculosis  of  the  Spine. 
The  variations  in  the  opsonic  power  after  sitting  up  indicate  autoinoculation  (Wright,  Lancet,  November  2, 

1907,  1229). 


antitoxin.  Here  we  furnish,  at  a  time  when  the  body  may  be  lacking 
in  ability  to  neutralize  the  toxin  of  diphtheria,  a  substance  which  is 
known  to  neutralize  diphtheria  poison  and  render  it  inert.     The  re- 


TU8ERCUL0 

OPSONfC 

INDEX 

14 
12 
NORMAL  10 
08 
0-6 


Fig.  212. — Induced  Autoinoculaxion. 
The  effect  of  fomentations  as  shown  by  variation  in  the  opsonic  index  (Wright,  Lancet,  November  2,  1907, 

1232). 

markable  reduction  in  mortality  in  diphtheria  attests  the  efficacy  of  this 
measure. 

These  examples  could  be  multiplied,  but  serve  their  purpose,  in  that 
they  clearly  indicate  that  we  can  do  no  better  than  to  seek  to  follow 


k 

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FOMENTATIONS      \ 

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20     21      22     23     24     25 

nature's  method  as  a  prototype  for  treatment 


627 


methods  which  nature  takes,  in  our  treatment  of  the  disease  produced  by 
microorganisms;  to  stimulate  the  protective  mechanism  of  the  body, 
if  we  can,  where  it  is  in  default,  and  offer  aid  when  and  where  it  faUs 
by  the  use  of  therapeutic  measures  that  fullil  actual  requirements  which 
nature,  for  one  reason  or  another,  cannot  fulfil. 

In  endeavoring  to  outline  a  reasonable  method  for  the  treatment  of 
localized  infectious  diseases  it  is  \A'ell  to  start  with  the  proposition  that 
each  case  presents  a  problem  in  immunization  which  the  protective 
mechanism  of  the  body  has  failed  to  solve;  that  it  becomes  our  business 
to  determine  wherein  the  bodily  offense  has  failed,  and  to  make  use  of 
such  measures  as  may  be  calculated  to  supply  the  deficiency,  to  the  end 


Dec 

8 

9 

10 

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60 

1 

GONOCOCCUS  KMEE. 
Fig.  213. — Induced  Adtoinoculation. 
Here  is  registered  by  a  fall  in  the  gono-opsonic  power  an  autoinoculation  due  to  the  tapping  of  a  gonorrheal 

joint. 

of  actually  neutralizing  toxic  products,  of  stimulating  the  normal  offensive 
processes  so  that  they  may  be  set  in  motion,  or  of  making  effective  a 
satisfactory  bodily  response. 

With'  the  realization  that  present  methods  are  to  a  large  degree 
inefficient,  and  in  some  degree  detrimental,  in  the  furtherance  of  cure 
of  localized  infections,  we  should  not  endeavor  to  elaborate  a  system 
of  treatment  which  will  be  an  adjunct  to  surgical  measures  or  to  any 
other  method  that  is  necessary  or  has  some  degree  of  efficiency,  but  should 
endeavor  to  give  each  method  or  procedure  its  proper  place,  modifying 
or  extending  each  according  as  it  is  efficient  in  the  solution  of  some  phase 
of  the  problem  in  immunization. 


628  THERAPEUTIC    IMMUXIZATIOX    AXD    VACCINE    THERAPY 

In  a  collection  in  book  form  of  his  papers  on  immunity  and  kindred 
subjects  we  find,  in  Wright's  dedication  to  ]Metchnikoff  and  Ehrlich, 
the  keynote  of  his  work:  "To  Eli  Metchnikoff  and  Paul  Ehrlich,  this 
endeavor  to  win  from  the  intellectual  seed  sown  by  them  a  harvest  in 
medicine  is  dedicated,  as  a  tribute  of  friendship  and  admiration,  by 
the  author."  Wright  holds  a  unique  place  in  medicine,  in  that  he  has 
been  able  to  interpret  the  many  facts  and  theories  that  years  of  research  have 
brought  out,  and  ivhich,  in  connection  ivith  the  results  of  his  own  in- 
vestigations, has  developed  the  only  thoroughly  rational  system  of  thera- 
peutics that  has  been  offered  to  medicine.  When,  hoAA'ever,  a  complete 
story  of  mimunity  shall  have  been  written,  it  will  doubtless  be  found  that 
at  the  present  time  there  was  much  to  learn. 

It  has  been  the  custom  in  the  earlv  stages  of  localized  infection  to 
apply  heat  in  the  form  of  soaks,  poultices,  etc.,  inasmuch  as  clinical 
obser\-ation  over  a  long  period  has  indicated  that  the  procedure  is  of  value. 
Until  Wright  indicated  that  such  measures  were  merely  aiding  and 
abetting  the  body  in  carrying  out  the  intent  which  it  normally  makes  to 
increase  the  blood-supply  to  the  part,  to  "even  up,"  as  Wright  terms  it, 
the  bacteriotropic  pressure  in  the  focus  of  infection  with  that  of  the 
blood-stream,  it  was  not  realized  that  the  import  of  the  hyperemic  stage 
of  infection  Avas  in  connection  with  an  attempt  of  the  body  to  focus  all 
its  antibacterial  forces  against  the  invading  bacteria.  The  applica- 
tion of  heat,  then,  may  be  called  a  rational  procedure,  because  it  serves 
to  enhance  the  value  of  the  process  which  the  body  normally  makes  use 
of  at  this  time.  In  the  early  stage  of  infection,  where  hmiphangitis  is 
present,  before  there  has  been  a  solution  of  tissue  in  the  focus,  there  has 
been  recommended  at  times  the  application  of  the  so-called  Gamgee 
dressing,  the  intent  of  which  was  to  so  constrict  the  lymphatics  leading 
from  the  infected  focus  that,  as  channels  for  the  spread  of  infection, 
they  might  be  efi'ectually  occluded.  Clinical  experience,  however,  seems 
not  to  ha-^-e  been  in  favor  of  its  usefulness  to  achieve  this  end.  It  seem.s 
very  probable,  from  considerations  referred  to  previously,  that  the  effect 
of  this  procedure  would  be  to  produce  a  passive  hyperemia  about  the 
focus  of  disease,  a  stagnation  of  hmiph  in  the  tissue  about  the  focus,  a 
loss  in  the  antitropic  power  of  the  lymph  in  contact  with  the  bacteria, 
and,  during  the  period  of  its  application,  the  production  of  conditions 
in  the  focus  that  were  less  resistant  to  the  growth  of  bacteria  than  would 
be  expected  to  be  the  case  without  it.  It  is  much  more  reasonable,  in 
the  hyperemic  stage  of  infection,  to  trust  to  the  ability  of  the  increased 
circulation  rapidly  and  continuously  to  replace  the  depleted  lymph  in 
the  focus,  rather  than  to  run  the  chance  of  furthering  bacterial  growth 


AUTOINOCULATION   BY   BIER'S   METHOD  629 

by  such  an  ill-advised  therapeutic  measure.  Further,  if  the  focus  of 
infection  were  at  all  extensi^'e,  the  forcing  of  lymph  into  the  focus  by 
passive  hyperemia  of  the  Gamgee  dressing  could  not  be  expected  to  do 
other  than  induce  an  autoinoculation,  in  size  depending  upon  the  extent 
of  the  lesion.  The  danger  here  would  derive  itself,  in  the  case  of  an 
autoinoculation  large  enough  to  JDe  toxic,  from  the  lowering  of  the  opsonic 
power  of  the  blood.  During  such  a  period  of  depression,  the  temporary 
diminution  in  the  power  to  destroy  bacteria  as  they  enter  the  blood- 
stream might  allow  of  the  development  of  new  foci  in  other  parts  of  the 
body. 

Since  the  excellent  results  produced  by  Bier,  his  pupils,  and  others 
have  been  published,  the  use  of  passive  hyperemia  has  been  applied 
to  all  sorts  of  infections  at  all  stages.  In  the  treatment  of  acute  local  in- 
fections, Bier's  passive  hyperemia  has  been  used  sometimes  disastrously. 
The  same  objection  to  its  use  in  the  early  stages  of  an  infection  may  be 
offered  as  against  the  Gamgee  dressing;  namely,  the  induction  of  a 
stasis  of  lymph  flow  in  the  focus  of  the  infection  at  a  period  when  the 
introduction  and  replacement  of  fresh  lymph  should  he  as  rapidly  carried 
out  as  possible.  At  this  stage  such  a  procedure  is  absolutely  contrary  in 
its  effect  to  the  measure  of  active  hyperemia  which  nature  endeavors  to 
enforce.  It  obstructs  the  natural  process  of  circulation,  and  should  not 
be  used  except  under  certain  conditions  and  in  rare  instances.  Where 
the  infection  is  extensive,  and  there  is  no  outlet  for  local  discharge,  the 
application  of  Bier's  passive  hyperemia  becomes  positively  dangerous, 
because  it  not  only  interferes  with  the  circulation  in  the  focus,  hut  also 
tampers  with  the  hacteriotropic  pressure  of  the  blood-stream,  in  that  when 
the  bandage  is  removed  there  wdll  soon  be  introduced  into  the  circula- 
tion a  flooding  of  bacteria-impregnated  lymph,  which  will  more  than 
likely  constitute  an  autoinoculation  of  toxic  proportion,  which  will  pro- 
duce an  immediate  lowering  of  the  hacteriotropic  power  and  cause  a 
diffusion  of  living  bacteria  to  parts  of  the  body  where  new  foci  may  be 
formed.  The  application  of  Bier's  bandage  can  never  be  without  its 
danger  in  the  case  of  local  infection,  where  there  is  no  local  exit  for  the 
discharge. 

It  is  quite  another  story  when,  in  one  of  the  extremities,  we  are  deahng 
with  tuberculous  ulcerations,  or  in  any  lesion  where  it  is  possible  to  in- 
duce a  free  discharge  of  lymph.  Thus,  the  forcing  of  lymph  into  the  focus 
will  drive  before  it  as  a  discharge  that  which  is  normally  present,  and 
the  circulation,  if  there  be  any,  will  be  outward  as  a  discharge,  and  the 
blood-stream  will  obviously  not  receive  autoinoculation  of  such  dimen- 
sion as  would  be  derived  in  the  case  of  closed  foci.     If  any  exception 


630  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERaPY 

is  to  be  made  in  the  rule  against  Bier's  passive  hyperemia  in  acute  closed 
infections,  it  may  be  occasionally  in  slight  superficial  processes,  in  which 
the  active  circulation  is  e\-idently  not  to  be  expected  to  be  efl&cient  in 
checking  the  growth  of  the  bacteria.  Infected  hair-follicles  on  the 
fingers  would  appear  sometimes  to  clear  up  rapidly  on  the  proper  applica- 
tion of  Bier's  bandage.  The  rational  technique  of  this  application 
in  such  cases  would  be  to  induce  passive  hyperemia  for  a  short  period — ■ 
say  from  ten  to  fifteen  minutes  only;  following  this,  the  bandage  is  to  be 
loosened,  and  the  finger  immersed  in  a  hot  soak  for  a  half  hour,  then 
the  same  procedure  repeated,  and  so  on,  the  period  being  varied  to  suit 
the  case.  The  rationale  of  this  procedure  is  as  follows:  We  force  the 
circulation  of  lymph  in  the  focus,  producing  swelling;  the  lymph  thus 
introduced  reinforces  that  which  is  present  by  its  opsonin  and  phago- 
cytes. It  is  not  left  there  long  enough,  however,  to  lose  all  its  opsonin 
and  become  a  culture-media  for  groNvth  of  the  bacteria.  The  focus 
being  small,  the  increase  in  circulation  being  moderate,  when  the  lymph 
is  returned  to  the  blood-stream  the  autoinoculation  would  ordinarily 
not  be  toxic  in  amount,  but,  on  the  contrary,  would  be  expected  to  form 
the  stimulus  for  an  active  immunizing  response  without  a  marked  im- 
mediate effect  in  reducing  the  bacteriotropic  pressure  of  the  blood. 
In  following  up  passive  hyperemia  by  measures  to  induce  a  more 
intense  active  hyperemia,  namely,  by  the  application  of  heat,  we  derive 
at  once  a  more  increased  active  circulation  in  channels  that  have  been 
dilated  as  a  result  of  the  passive  hyperemia.  Such  a  repetition  of  passive 
and  active  hyperemia  v/ould  be  more  effective  in  a  case  where  the  cir- 
culation is  apt  to  be  poor,  as  in  the  superficial  infection,  than  the  nor- 
mally increased  circulation  of  active  hyperemia  or  than  that  which 
could  be  induced  by  the  application  of  heat. 

If  the  initial  attack  of  the  body  mechanism,  the  serum  and  phagocytic 
cells,  has  failed,  and  solution  of  tissues  takes  place,  new  indications  for 
treatment  arise.  We  have  in  the  pus  a  fluid  almost  totally  deficient 
in  opsonic  power,  with  leukocytes  which  are  incapable,  even  in  the 
presence  of  opsonin,  to  ingest  bacteria;  a  fluid  which,  in  the  case  of 
pyogenic  infections,  contains  a  tryptic  ferment  which,  when  exerted 
against  stride  of  connective  tissue,  produces  their  solution  and  opens  up 
channels  for  the  extension  of  bacterial  growth.  It  is  impossible,  on 
account  of  the  swelling  and '  coagulation  of  lymph,  which  produce  a 
plugging  of  the  capillaries  and  lymph-spaces,  to  induce  an  effective 
lymph-stream  from  the  circulating  blood.  The  indication,  therefore, 
in  order  to  limit  the  extension  of  the  process,  is  to  free  the  tissues  of  the 
tryptic  pus,  to  produce  an  active  hyperemia  by  artificial  means  about 


THE    EVILS    OF    ANTISEPTICS  63 1 

the  outskirts  of  the  infection,  in  order  that  the  full  bacteriotropic  pressure 
of  the  blood  may  be  exerted  at  points  where  the  bacteria  might  otherwise 
cultivate  themseh'es  and  produce  extension.  The  effect  of  such  drainage 
-at  once  is  to  reduce  the  pressure  of  pus  in  the  cavity,  and  by  ridding  it 
-of  the  pus,  temxporarily  to  limit  extension  of  the  process.  At  this  point 
it  has  been,  until  recently,  the  custom  to  attempt  the  destruction  of  the 
bacteria  which  must  be  cultivating  themselves  in  the  walls  of  the  abscess 
cavity,  by  means  of  antiseptics.  As  has  been  referred  to  before,  the 
absolute  failure  of  this  attempt  to  accomplish  its  purpose  is  attested 
by  the  fact  that  in  commion  use,  at  present,  only  irrigations  of  salt  solu- 
tion or  the  mildest  antiseptics  are  used.  As  Ehrlich  puts  it,  strong 
.antiseptics  are  not  only  parasitropic  and  histotropic — that  is,  when  they 
are  sufficiently  strong  to  kill  bacteria  they  also  destroy  tissue-cells. 
Not  only  do  they  do  this,  but,  as  Wright  has  suggested,  they,  by  irritation, 
induce  a  flow  of  lymph  into  the  focus,  the  antibacterial  power  of  which 
is  rendered  ineffective  by  the  antiseptic.  The  antiseptic  cannot  be 
expected  to  come  into  contact  wdth  all  the  bacteria,  and  the  cells  which 
have  been  devitalized,  and  the  lymph  rendered  inert  by  the  antiseptics, 
cannot  be  other  than  a  more  or  less  satisfactory  medium  in  which  the 
bacteria  can  further  cultivate  themselves.  Whether  or  not  this  con- 
ception is  correct,  it  is  a  fact  that  the  use  of  strong  antiseptics  is  not 
effective  in  furthering  the  healing  process.  It  is  perfectly  obvious 
that  advantages  may  be  gained  by  hot  applications  leading  to  increase 
in  local  circulation.  It  is  further  obvious  that  large  numbers  of  bacteria 
will  be  present  in  the  walls  of  the  cavity  w^hich  cannot  be  efficiently 
reached  by  lymph  from  the  circulating  blood. 

The  conditions  that  the  body  has  achieved,  which  mark  success  in 
prevention  of  generalized  infection,  register,  nevertheless,  at  this  point, 
failure,  or  partial  failure,  inability  to  produce  conditions  that  will  bring 
blood-serum  in  effective  contact  with  the  microorganisms  whose  de- 
struction is  necessary  for  cure. 

At  this  point  it  has  been  found  that  Bier's  suction  has  a  place  of 
distinct  value  in  that,  by  producing  negative  pressure  in  the  cavity, 
lymph  is  forcibly  drawn  through  its  walls,  and  lymph  from  the  blood- 
■stream  is  enabled  to  flow  in  and  take  the  place  of  that  which  has  lost 
its  efficiency  in  contact  with  the  bacteria.  This  procedure  has  been 
followed  in  many  cases  by  most  excellent  results  in  the  treatment  of 
these  conditions,  but  the  indictment  against  it  as  a  method  is  that  it 
does  not  take  into  consideration  the  fact  that  the  capillaries  and  lymph- 
spaces,  most  of  them,  are  plugged  with  fibrin,  that  any  forcible  exuda- 
tion which  it  induces  is  apt  to  be  accompanied  by  hemorrhage  on  account 


632  THERAPEUTIC    IMMUXIZATIOX    AXD    VACCIXE    THERAPY 

of  rupture  of  small  vessels.  Further,  to  be  useful,  it  should  be  applied 
frequently,  say,  every  few  hours,  and  in  practice  this  is  commonly  not 
feasible. 

Recognizing  the  essential  factor  in  cure  is  the  free  bathing  of  the 
bacteria  in  the  walls  of  the  cavity  with  fresh  serum  from  the  blood,  with 
its  high  antitropic  power,  measures  should  be  sought  that  would  render 
this  continuous,  without  producing  injury  to  the  tissue  or  hemorrhage. 
To  this  end  Wright  has  devised  a  solution,  composed  of  i  per  cent, 
sodium  citrate  and  4  per  cent,  sodium  chlorid,  with  which  the  ca\ity 
may  be  irrigated.  As  a  dressing,  a  pad  wet  in  the  solution  and  kept  con- 
tinuously wet  should  be  applied.  The  effect  of  the  sodium  citrate  in 
this  solution  is  to  produce  a  precipitation  of  calcium  salts  in  the  lymph 
and  thus  prevent  coagulation.  Hence  its  presence  in  the  wound  cavity 
insures  a  comparatively  free  exit  for  lymph  discharge.  The  sodium 
chlorid  content,  being  a  so-called  hypertonic  solution,  by  osmotic  ac- 
tion draws  lymph  through  the  walls  of  the  ca\ity,  all  obstruction  to 
the  flow  of  which  has  been  remo\'ed  by  the  sodium  citrate,  in  the  fact 
that  it  forestalls  any  plugging  of  the  capillaries  or  lymph-spaces  by 
clotting  lymph.  Thus  is  pro\ided  for  a  free  discharge,  and  by  the  aid 
of  hot  poultices  or  applications  over  the  citrate  and  salt  dressings,  in- 
creased blood-supply  is  brought  to  the  part.  Hence  there  should  be 
a  continuous  circulation  of  lymph  of  high  antibacterial  power  from  the 
blood-stream  through  the  walls  of  the  ca\ity  and  outward.  The  proof 
of  the  efficacy  of  this  measure  is  to  be  found  in  its  daily  use.  It  is  pos- 
sible to  insure  a  continuously  free  drainage  from  any  ca\ity,  the  opening 
of  which  does  not  mechanically  close  itself,  without  the  use  of  any  wick 
or  drain  whatsoever.  Such  an  abscess  ca^^ty  will  ne\'er  be  found  to 
crust  itself  over  if  the  solution  of  citrate  and  salt  be  continuously  used. 
If  it  be  necessary  to  use  measures  to  keep  the  exit  open,  rubber  dam  or 
rubber  tubing  is  all-sufficient.  The  use  of  zi'icks,  as  commonly  applied 
(without  sodium  citrate  and  salt  solution),  is  a  delusion  ivhich  it  is  hard 
to  dispel.  It  is  probable  that  after  a  time  clinical  observation  will  arrive 
at  the  point  where  it  will  gra\^tate  away  from  wicks,  just  as  it  has  away 
from  the  use  of  strong  antiseptics.  In  most  cases  a  wick,  in  a  few  hours, 
through  coagulation  of  lymph  and  pus,  becomes  more  of  a  plug  than  a 
drain.  It  was  only  the  other  day  that  the  writer  was  called  to  treat 
a  case  of  cellulitis  of  the  neck'  in  which  there  had  been  two  operative 
wounds,  which  wounds  were  found  to  be  connected  by  a  continuous 
gauze  wick.  The  wick  was  dry  and  stiff,  and  upon  removal  several 
dramis  of  pus  were  evacuated.  Gauze  wicks  most  decidedly  have  their 
place,  but  it  is  not  to  promote  drainage. 


SODIUM   CITEATE    AXD    SODIUM    CHLORID  633 

Conclusive  evidence  that  sodium  citrate  and  sodium  chlorid,  as  a 
dressing  and  an  irrigation,  contribute  to  the  destruction  of  bacteria 
in  the  walls  of  the  abscess  cavity  has  been,  and  may  be,  at  any  time  ob- 
tained in  the  laboratory.  The  first  demonstration  of  this  observed  by 
the  writer  was  in  Wright's  clinic  in  London. 

A  patient  came  to  the  clinic  for  treatment  of  an  infected  wound  of  the  thumb,  the 
result  of  operation  for  a  streptococcus  infection  on  the  previous  day.  When  first  seen, 
in  the  wound  was  a  thick  coagulated  mass  of  pus  and  lymph,  which  obstructed  all  flow. 
The  patient  had  a  temperature,  and  the  local  condition  showed  swelling,  tenderness,  and 
was  the  cause  of  much  pain.  In  order  to  test  as  to  whether  the  phagocytic  activity  be- 
neath this  crust  was  at  all  efficient,  the  crust  was  removed  and  smears  were  made  from 
fluid  expressed  at  the  base  of  the  wound.  It  was  found  that  most  of  the  phagocytics  were 
disintegrated,  but  that  some  appeared  to  be  normal.  It  is  only  in  the  rarest  instances  that 
the  streptococci  were  to  be  demonstrated  within  a  leukocyte,  but,  on  the  contrar}^,  there 
were  a  profusion  of  streptococci  growing  in  long  chains  outside  oj  the  phagocytes.  The 
patient  was  given  a  small  inoculation  of  vaccine,  and  a  dressing  of  sodium  citrate  and  sodium 
chlorid  was  apphed  to  the  wound.  The  patient  was  told  to  soak  the  thumb  one  hour  out 
of  four  until  the  next  day,  and  between  times  to  apply  hot  poultices  of  the  same  solution  to 
the  lesion.  On  the  following  day,  macroscopicaUy,  there  was  an  entirely  different  picture. 
The  thumb  w^as  less  swollen,  less  red,  there  was  free  discharge  and  an  absence  of  crust. 
The  temperature  was  normal.  A  smear  from  the  lymph,  expressed  in  the  same  manner, 
from  the  depths  of  the  cavity,  showed  a  striking  difference  from  that  seen  on  the  pre\'ious 
day.  No  broken-down  leukocytes  were  to  he  seen.  In  practically  all  the  leukocjles  were 
found  many  inclusions  of  streptococci  in  pairs  and  in  short  chains,  while  outside  the  leuko- 
cytes there  were  no  long  chains  to  be  seen  and  cocci  were  only  occasionally  found. 

It  is  easy  in  this  manner  to  demonstrate  the  efficiency  of  this  sodium 
citrate  and  sodium  chlorid  solution  in  accomplishing  what  the  body 
fails  to  accomplish  in  the  provision  of  a  circulation  of  effective  lymph- 
stream  in  a  focus  of  infection,  and  maintenance  of  the  leukocytes  in  a 
healthy  condition  for  phagocytosis. 

The  abolishment  of  wicks  and  antiseptics  in  such  localized  pyogenic 
infections  has  been  followed,  in  the  observation  of  the  writer  in  Wright's 
clinic  and  later  in  his  own  cases,  when  sodium  citrate  and  sodium  chlorid 
solution-  have  been  used  instead,  by  absolutely  and  consistently  good 
results.  Here,  then,  by  furnishing  aid  at  the  point  where  nature  fails, 
we  enable  the  protective  mechanism  to  pursue  its  course  in  the  destruc- 
tion of  bacteria  in  approximately  the  natural  and  unobstructed  manner. 

When  the  surgeon  takes  up  his  knife  to  produce  the  evacuation  of 
pus  of  pyogenic  organisms  in  localized  foci,  it  must  be  with  the  full 
realization. that  the  operation  is  not  an  end  in  itself,  but  is  merely  furnish- 
ing assistance  in  achieving  the  riddance  of  pus  and  in  preventing  exten- 
sion of  the  disease  by  its  tryptic  ferment;  that  he  is  accomplishing  the 
first  step  necessary  in  rendering  the  immunizing  mechanism  of  the  body 
efficient  where  it  would  otherwise  fail;    that,  by  the  relief  of  pressure, 


634  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

he  allows  of  a  fresh  supply  of  lymph  with  higher  bacterial  power  than 
that  in  the  focus;  and  with  it,  leukocytes  that  are  capable  of  ingesting 
bacteria  to  come  into  contact  with  the  organisms  which  are  responsible 
for  the  disease.  With  this  in  mind,  the  extent  of  his  incision  will  be 
much  more  limited  than  it  has  been  the  common  custom  to  make. 
The  so-called  wide  surgical  incision  will  give  way  to  the  much  despised 
small  or  medical  incision,  particularly  where  it  is  desirable  to  eliminate, 
so  far  as  possible,  a  large  scar.  The  small  incision,  in  that  it  can  be  kept 
freely  open  by  means  of  sodium  citrate  and  sodium  chlorid  dressings, 
will  be  quite  as  effectual  as  a  drain,  and  at  the  same  time  will  allow 
quite  as  free  a  circulation  of  lymph  as  a  larger  incision,  will  heal  more 
rapidly,  and  present  a  much  smaller  scar.  In  the  case  of  a  single  abscess, 
where  there  is  no  tendency  to  the  development  of  furunculosis,  the 
measures  described  will  be  efficient  in  promoting  a  cure,  but  where  there 
are  other  foci  and  a  tendency  to  repetition,  it  will  be  necessary  to  use 
some  effective  measure,  which  shall  meet  in  a  rational  manner  the  defect 
in  the  protective  mechanism  which  is  responsible  for  the  condition. 

It  is  manifestly  impossible  to  transfer  the  antibacterial  elements  of 
the  blood  through  the  obstruction  produced  by  the  swollen  walls  of  the 
infected  focus  into  the  pus  therein  contained  and  insure  their  application 
against  present  bacteria.  It  is  quite  as  impossible  to  accomplish  the 
same  in  the  case  of  infiltrating  infection,  such  as  carbuncle  and  phlegmon. 
The  indications  here  are  surgical  measures.  Their  effect,  leading  to 
destruction  of  bacteria  and  the  prevention  of  extension  of  the  infectious 
process,  has  been  discussed.  It  should  here  be  noted,  in  connection 
with  the  cause  of  extension  in  pyogenic  processes  (the  tryptic  ferment 
set  free  from  the  leukocytes) ,  that  the  inflowing,  lymph,  after  the  evacua- 
tion of  pus,  plays  an  active  part  also  in  the  prevention  of  spread,  in  that 
it  neutralizes  the  tryptic  ferment  in  the  pus. 

We  may  further  elaborate  the  rationale  of  the  efficiency  of  surgical 
measures  in  cure  by  considering  the  autoinoculating  effect  which  the 
operative  procedure,  if  it  be  at  all  extensive,  has  induced  in  the  case  of 
phlegmon,  carbuncle,  or  in  extirpating  operations.  Surgery  here  has 
unwittingly  been  a  contributing  factor  to  recovery,  in  furnishing  as  an 
autoinoculating  stimulus  bacteria  and,  their  products,  which  the  trauma 
to  the  tissue  has  set  free  in  the  circulating  blood  and  lymph-spaces. 
Thus  we  should  expect  to  have  produced  an  immunizing  response  in  the 
increase  in  opsonic  power  of  the  blood.  In  the  chart  relating  to  auto- 
inoculation,  produced  by  operation  for  extirpation  in  localized  tuberculo- 
sis (Fig.  209),  we  have  as  evidence  that  this  takes  place  the  record  of 
opsonic  determinations,  which  are  indicative  that  immunizing  response 


SMALL   INCISIONS    FOR    TUBERCULOSIS  635 

has  taken  place,  and  that  autoinoculation  must  have  produced  it. 
Such  immunizing  response  is  registered  as  a  result  of  operative  pro- 
cedures which  introduce  bacteria  into  the  blood,  and,  so  far  as  they  go, 
tend  to  the  cure  of  the  patient  by  fortifying  the  blood-stream.  Such 
autoinoculations,  however,  are  only  temporarily  efficient. 

In  the  case  of  an  abscess  cavity,  due  to  the  breaking  down  of  a 
tuberculous  focus,  such  as  a  lymph-node,  conditions  are  not  quite  the  same 
as  in  an  abscess  due  to  pyogenic  organisms.  This  is  due  to  the  fact  that 
the  pus,  in  its  low  content  of  polymorphonuclear  leukocytes,  from  the 
breaking  down  of  which  tryptic  ferment  is  obtained,  would  not  be  ex- 
pected to  exert,  and  in  fact  does  not  exert,  much  of  a  dissolving  action 
upon  the  connective  tissue,  and  hence  there  is  to  be  observed  no  tendency 
to  spread,  as  is  found  in  the  case  of  tryptic  pus  of  pyogenic  organisms. 
Further,  the  walling  off  of  the  limiting  membrane  of  the  node  is  active  in 
preventing  extension.  It  is  possible,  therefore,  if  desirable,  to  postpone 
the  evacuation  of  such  a  cavity  without  danger  to  the  patient,  and,  as 
will  be  seen  later,  in  the  treatment  of  tuberculosis,  it  may  be  of  advan- 
tage to  postpone  evacuation  for  certain  reasons. 

The  occurrence  of  secondary  infection  in  tuberculous  processes 
makes  it  desirable  to  evacuate  the  pus  through  as  small  an  opening  as 
possible.  Where  wide  incision  is  used,  the  chance  of  secondary  infec- 
tion is  much  greater  than  if  pus  be  aspirated  or  drained  through  a  minute 
incision.  The  absence  of  tryptic  action  renders  it  possible  to  abstract 
the  pus  by  means  of  an  aspirating  needle  and  syringe  when  necessary. 
Such  aspiration  may  ha\-e  to  be  repeated  frequently,  but  the  final  result 
will  commonly  be  quite  as  good  as  that  obtained  where  incision  is  made, 
so  far  as  efficient  drainage  goes;  there  will  be  no  sizable  scar,  and  the 
chance  of  secondary  infection  will  be  minimized. 

Where  bacteria  are  growing  in  a  serous  cavity,  clinical  improvement 
is  known  to  follow  evacuation  of  the  contents  of  such  a  cavity.  We  have 
seen  that  the  opsonic  power  of  the  blood,  in  contact  with  bacteria  growing 
in  this  manner,  is  much  lower  than  that  of  the  circulating  blood.  The 
excellent  results  which  sometimes  occur  in  the  case  of  tuberculous 
peritonitis,  which  have  been  attributed  to  opening  up  of  the  abdomen 
and  allowing  air  to  enter,  are  readily  explained  by  the  fact  that  the 
abstraction  of  fluid  of  low  antibacterial  power  has  been  followed  by  an 
inflow  of  lymph  from  the  blood-stream,  with  considerably  higher  anti- 
bacterial power.  It  would  seem  that  tapping  should  be  quite  as  efficient 
in  tuberculous  peritonitis  as  a  celiotomy,  in  that  the  same  result  in  this 
replacement  of  fluid  follows. 

The  persistence  of  a  discharging  sinus  depends  primarily  on  the 


636  THERAPEUTIC    IMMUNIZATION    AND    VACCINE   THERAPY 

presence  of  a  focus  of  disease  at  its  base.  When  this  is  removed,  how- 
ever, so  far  as  possible,  the  discharge  is  still  apt  to  continue,  and,  infected 
with  pyogenic  organisms,  as  it  commonly  is,  we  must  conclude  that  these 
organisms  are  growing  in  the  walls  of  such  sinus,  because  of  their  isola- 
tion from  the  active  blood-stream.  We  see  reason  for  this  in  the  walling 
off  produced  by  the  granulation  tissue,  which  constitutes  the  wall  of 
the  sinus,  and  the  clotting  of  lymph  and  blood  in  its  exit. 

Fundamental  to  the  cure  of  these  conditions,  therefore,  is  the  use 
of  measures  which  will  induce  a  stream  of  lymph  through  the  walls  of 
the  sinus  into  contact  with  the  bacteria.  The  use  of  sodium  citrate 
and  salt  solution  as  an  irrigation,  in  association  with  cupping,  may  pro- 
duce the  desired  effect.  The  use  of  wicks  to  keep  such  sinuses  open  is 
inefi&cient,  for  the  reason  stated  previously.  Frequent  probing  does  more 
harm  than  good,  in  that  by  trauma  to  the  tissue  it  is  apt  to  produce 
hemorrhage,  and  through  clotting,  the  sinus  is  obstructed;  abstraction 
of  the  protective  substances  in  the  effused  blood  rapidly  takes  place,  the 
result  being  that  an  excellent  culture-medium  is  produced  for  the  further 
growth  of  the  bacteria.  Where  the  situation  admits  of  it,  the  laying  open 
of  a  sinus  by  operative  procedure,  the  application  of  iodin,  etc.,  proves 
in  practice,  particularly  in  the  fistulous  sinuses  about  the  rectum,  to  be 
the  most  rapidly  efficient  procedure,  in  that  the  whole  length  of  the  sinus 
is  opened  up  and  it  granulates  from  the  bottom. 

Wright  gives,  as  a  fundamental  principle  in  the  treatment  of  localized 
infections,  that  as  full  a  lymph-stream  as  possible  should  be  caused  to 
flow  through  the  infected  focus,  in  order  that  the  antibacterial  elements 
and  leukocytes  of  the  blood-stream  may  come  into  effective  operation 
in  the  extravascular  focus  of  infection.  Up  to  this  time  we  have  con- 
sidered the  methods  by  which  this  ideal  may  be  obtained ;  that  they  are 
all  directed  toward  the  furthering  of  some  process  which  the  body  naturally 
directs  toward  the  destruction  of  bacteria,  or  to  rendering  assistance  at 
some  point  where  such  process  fails,  by  removing  such  obstructions  as  may 
inhibit  its  proper  working  out.  We  have  considered  definitely  the  place 
of  surgery  in  removing  such  obstruction,  and  have  seen  that,  in  con- 
sideration of  the  conditions  to  be  brought  about  by  such  procedures, 
the  extent  of  operation  may  be  commonly  lessened  if  it  is  constantly 
borne  in  mind  what  the  conditions  are  that  we  desire  to  achieve. 

The  blood-stream  is,  as  if  were,  a  reservoir  of  antibacterial  sub- 
stances. It  is  higher  in  its  bacterial  power  than  any  other  fluid  in  the 
body.  It  is  commonly  many  times  as  high  as  a  fluid  in  the  infected 
focus.  It  is  not  necessary  to  enlarge  upon  the  proposition  that,  if  the 
blood-stream  is  low  in  its  antibacterial  content,  it  cannot  have,  in  its 


VACCINES   IN   LOCALIZED   INFECTIONS  637 

action  upon  the  microorganisms  in  the  infected  focus,  as  destructive 
an  effect  as  if  the  content  in  bacterial  substances  were  greater.  We  have 
seen  that  in  localized  infections  the  opsonic  power  of  the  blood  is  con- 
sistently subnormal,  and  in  many  cases  not  more  than  -^q  to  -^-q  the  normal. 

Bulloch^  showed  that  in  cases  of  lupus,  where  the  opsonic  power  of 
the  blood  was  markedly  subnormal,  treatment  with  x-ray  and  Finsen- 
ray  had  little  effect  in  producing  a  cure,  but  when  the  opsonic  power 
was  Dormal  or  above,  these  measures  appeared  to  be  much  more  efficient. 
On  similar  considerations,  Wright  bases  another  principle  which  is 
fundamental:  that  in  every  case  where  the  antibacterial  power  of  the 
patient's  blood  falls  below  the  standard  under  which  the  body  is  making 
an  effective  response  to  infection,  measures  to  increase  the  antibacterial 
power  of  the  blood  should  be  used.  We  have  seen  that  it  is  possible,  by 
the  injection  of  bacterial  vaccine,  composed  of  killed  organisms  of 
exactly  the  variety  of  those  which  are  the  infecting  agents,  to  bring 
about  an  immunizing  response  in  the  achievement  of  a  heightened 
bacteriotropic  power  of  the  circulating  blood,  and  if  the  dosage  of 
vaccine  be  of  proper  size,  and  given  at  proper  intervals,  the  high  bac- 
teriotropic power  may  be  more  or  less  constantly  maintained.  The 
result  of  such  inoculation  will  be,  as  Wright  puts  it,  that  the  citadel  of 
the  circulating  blood  will  be  more  secure  against  septicemic  invasion. 
Bacteria  entering  the  blood  will  be  killed  instead  of  being  carried  from 
point  to  point  unharmed  and  in  a  condition  to  establish  new  foci.  The 
blood  will  have  at  its  disposal  a  reservoir  of  antibacterial  fluid  of  satis- 
factory potency  and  available  for  flushing  any  bacterial  nidus  in  the  tissue, 
wherever  it  may  be. 

The  first  principle  referred  to,  the  determination  of  lymph  to  the 
focus  of  infection,  comes  next  into  play,  in  that  it  requires  the  use  of 
measures  which  shall  bring  into  operation  in  the  focus  of  infection  as 
nearly  the  full  bacteriotropic  pressure  of  the  blood  as  possible. 

As  has  previously  been  pointed  out,  in  certain  infections  where 
there  is  no  outlet  for  discharge,  determination  of  lymph  to  the  part 
results  in  possibly  an  overwhelming  autoinoculation,  the  result  of  which 
is  to,  for  a  time,  produce  a  lowering  of  the  opsonic  power  of  the  blood- 
stream. Where  such  an  event  would  take  place,  the  use  of  measures 
to  increase  the  passive  congestion  of  such  a  focus  may  be  distinctly 
dangerous,  in  that  they  break  down  for  the  time  being  the  barrier  which 
the  blood-stream  offers  against  bacterial  invasion.  As  a  result  of  ex- 
cessive autoinoculation,  the  resistance  to  spread  of  infection  is  not  only 
diminished,  but  also  the  power  of  the  blood  to  exert  a  favorable  action 

^  Trans.  Path.  Soc.  London,  1905,  Ki,  part  3. 


638  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

upon  the  bacteria  in  the  original  focus  leading  to  their  destruction  will 
be  diminished  or  lost.  In  the  words  of  Wright,  "where  we  have  to 
choose  between  the  lowering  of  the  bacteriotropic  pressure  of  the  blood- 
stream, by  inducing  autoinoculation  and  leaving  the  bacteria  in  the 
localized  focus  unharmed,  we  ought  to  choose  the  latter;  that  we  must 
safeguard  the  citadel  of  the  blood  against  septicemic  invasion  and  prevent 
the  passage  of  living  bacteria  from  one  point  to  another.''^  These  con- 
siderations outweigh  all  others,  and  must  be  borne  in  mind  whenever 
Bier's  passive  hyperemia  is  used  as  a  therapeutic  measure. 

It  would  at  once  suggest  itself  that  we  should  find  in  Bier's  passive 
hyperemia,  as  applied  to  certain  infections,  as  tuberculous  joints,  ulcera- 
tions, etc.,  where  such  can  be  applied,  a  measure  which  would  not  only 
increase  the  antibacterial  power  of  the  blood,  but  at  the  same  time 
cause  a  determination  of  lymph  to  the  focus  of  disease.  Such  treatment 
is  advantageous,  perhaps,  in  certain  ways,  in  that  we  are  always  using 
the  correct  vaccine;  in  that  we  are  not  confronted  with  the  difficulty 
of  isolating  organisms  and  preparing  vaccine;  that  there  is  no  delay  in 
its  application;  that  stagnant  lymph  may  be  replaced  by  lymph  of 
higher  bacteriotropic  power  and  which  will  exert  a  beneficial  action. 
The  disadvantages  are,  however,  that  autoinoculations  consist  of  living 
bacteria,  as  well  as  their  products,  carried  into  the  blood-stream;  that 
autoinoculations  constitute  unmeasured  doses  of  bacteria;  that  the 
dose  may  at  any  time  be  excessive  in  the  case  of  an  infected  focus  of 
considerable  size;  that  in  the  case  of  a  small  focus  the  autoinoculation 
may  be  too  small  to  be  beneficial,  and  where  bacterial  growth  is  gradually 
lessened  by  immunizing  response  to  previous  autoinoculation,  the  size 
of  the  autoinoculations  will  be  considerably  lessened;  in  cases  where 
there  is  actually  required  a  gradual  increase  in  the  amount  of  auto- 
inoculation in  order  to  produce  adequate  immunizing  response;  that 
autoinoculations  cannot  be  made  use  of  in  infections  where  the  location 
is  unsuitable.  The  use  of  bacterial  vaccines,  on  the  other  hand,  are  more 
advantageous  in  most  cases,  because  the  dose  can  be  accurately  measured 
and  can  be  increased  at  will;  it  is  not  so  time-consuming  in  its  applica- 
tion for  both  the  patient  and  the  practitioner  as  the  procedure  of  auto- 
inoculation. It  is  infinitely  safer,  because  it  does  not  depend  for  its 
usefulness  upon  the  entrance  into  the  blood-stream  of  living  organisms. 

The  rational  application'  for  bacterial  vaccine  is  unquestionably 
met  in  localized  infections,  in  that  it  furnishes  a  stimulus  to  the  im- 
munizing mechanism  which  is  absolutely  necessary  for  the  elabora- 
tion of  specific  protective  substances,  and  which  is  lacking  because, 
through  the  segregated  condition  of  the  focus  of  infection,  the  blood- 


THE    PREVENTION    OF    AUTOINOCULATION  639 

Stream  is  unable  to  derive  for  itself  a  sufficient  quantity  of  bacteria  to 
constitute  an  effective  autoinoculation;  in  that  the  vaccine  stimulates  the 
otherwise  dormant  protective  mechanism  to  efficient  response,  it  is  a 
rational  procedure,  and  is  worthy  of  a  place  in  a  system  for  immunization 
which  has  for  its  dominating  idea  the  furtherance  of  nature's  own  proc- 
esses in  the  struggle  against  bacterial  infection. 

As  a  type  of  cases,  which,  in  spite  of  obvious  autoinoculation,  show 
little  tendency  to  improve,  I  would  refer  to  those  of  persisting  abdominal 
sinus  sometimes  following  appendectomy,  which  continue  to  discharge 
profusely  pus  which  may  contain  colon  or  streptococcus  chiefly  and 
sometimes  other  organisms.  As  evidence  that  autoinoculation  is  tak- 
ing place,  we  have  an  irregular  temperature,  symptoms  of  toxemia,  and, 
if  the  opsonic  index  is  determined  from  day  to  day,  we  find  wide  fluctua- 
tions above  and  below  normal  at  different  times.  Here  we  obviously 
have  entry  into  the  blood  at  times  of  living  bacteria  and  their  products, 
even  though,  so  far  as  is  possible,  any  pockets  or  collections  of  pus  in 
and  about  the  sinus  have  been  carefully  evacuated.  It  is  clear  that 
these  autoinoculations  are  not  effective  in  leading  toward  a  cure.  If 
we  may  presume  to  anticipate  a  little  the  discussion  of  the  actual  use 
of  vaccines,  we  must  conclude  that  these  autoinoculations  are  either 
excessive  or  too  often  repeated  to  furnish  a  basis  for  satisfactory  im- 
munizing response. 

The  proposition  that  it  should  be  our  first  endeavor,  by  using  such 
measures  as  we  have  at  our  command,  to  prevent,  so  far  as  possible, 
these  toxic  autoinoculating  doses  of  living  bacteria,  which  emanate 
from  the  focus  and  enter  the  blood-stream,  needs  no  elaboration.  If  it  is 
possible  in  some  degree  to  control  the  autoinoculation,  we  have  in  this 
way  reduced  the  condition  to  a  semblance  of  localized  infection,  and, 
as  such,  we  see  in  it  an  indication  for  vaccine  so  given,  that  a  consistently 
favorable  immunizing  response  may  be  obtained  on  the  part  of  the  organ- 
ism. Irregular  and  ill-timed  autoinoculation  may  unquestionably  take 
place  as  a  result  of  the  entrance  into  the  body  of  numbers  of  bacteria 
which  are  not  sufficiently  large  to  produce  intoxication.  They  may 
even  end  in  recovery,  as  a  result  of  a  more  or  less  efficient  immunizing 
response.  In  acute  fulminating  infections,  resulting  from  infected 
wounds,  we  obviously  have  conditions  of  excessive  autoinoculation, 
and,  in  so  far  as  the  disease  spreads  and  toxic  symptoms  develop,  efficient 
immunizing  response  is  not  obtained.  In  the  case  of  tuberculous  joints 
which  show  evidence  in  temperature,  or  in  local  symptoms,  that  the 
disease  is  progressing  unfavorably,  we  may  properly  assume  that  auto- 
inoculation is  taking  place,  but  that  it  is  either  excessive  in  amount  or 


640  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY       ' 

SO  ill  timed  that  it  does  not  induce  the  immunizing  mechanism  to  re- 
spond successfully.  In  pulmonary  tuberculosis  of  the  febrile  type, 
we  must  assume  that  toxic  doses  of  bacteria  are  being  taken  into  the 
blood,  and,  in  that  the  disease  progresses,  the  immunizing  response  is 
not  efficient.  It  has  been  clearly  shown  by  Urwick^  that  febrile  cases  of 
pulmonary  tuberculosis  are  subject  to  a  succession  of  positive  and  nega- 
tive phases — in  other  words,  to  fluctuations  of  the  antibacterial  power — ■ 
which  can  only  be  due  to  excessive  autoinoculation. 

These  instances  are  given  to  emphasize  that  even  when  autoinoculation 
takes  place,  it  is  commonly  not  efficient  in  producing  a  cure,  and  that,  there- 
fore, the  first  requirement  is  to  eliminate,  so  far  as  possible,  such  autoin- 
oculation. The  means  that  we  have  at  hand  to  bring  this  about  are 
several.  In  the  acute  fulminating  infections  where  pus  is  forming,  is 
under  pressure,  and  by  its  tryptic  ferment  is  extending,  we  have  conditions 
which  may  consistently  be  expected  to  be  conducive  to  autoinoculation, 
and  we  have  in  these  infections  the  temperature  to  prove  that  this  is  so. 
The  use  of  surgery  to  relieve  the  pressure  in  the  pus  cavity,  and  of  other 
local  measures  cited  to  induce  a  free  percolation  of  lymph  from  the  blood- 
stream into  the  cavity,  is  the  most  efficient  measure  at  this  time  finally  to 
inhibit  autoinoculation.  In  a  case  of  phlegmon,  extensive  incision 
may  be  necessary  to  bring  the  same  condition  about;  in  the  case  of  a 
gonococcus  joint,  tapping  may  be  indicated;  in  the  case  of  a  tuberculous 
joint,  fixation;  in  a  case  of  caries  of  the  spine,  absolute  rest  and  surgery. 
Since  in  a  case  of  pulmonary  tuberculosis  it  has  been  demonstrated 
by  means  of  the  opsonic  index  that,  following  exercise  such  as  walking, 
deep  breathing,  calisthenics,  etc.,  autoinoculation  takes  place,  we 
must  conclude  that  such  autoinoculation  is  due  to  the  increased  blood- 
supply  to  the  lung  and  the  more  rapid  breathing  which  exercise  induces. 
Hence  to  eliminate  autoinoculation  absolute  rest  in  bed  should  be  re- 
quired, and  in  practice  such  procedure  is  found  in  many  cases  finally 
and  absolutely  to  eliminate  autoinoculation  of  any  but  a  favorable 
amount.  We  have  then,  in  surgical  measures  and  in  absolute  rest  to 
the  part  involved  in  the  infection,  measures  for  eliminating  autoinocula- 
tion. Wright  further  advises  the  additional  attempt  to  diminish  auto- 
inoculation by  lessening  the  lymph-stream  in  the  focus  of  disease.  He 
advises  internal  administration  of  calcium  salts  to  the  end  of  rendering 
the  blood  more  coagulable  arid  less  penetrating,  hoping  that  thus  it  will 
come  into  contact  with  and  take  up  fewer  bacteria. 

The  part  that  surgery  has  played  in  the  cure  of  infectious  processes 
has  been  to  safeguard   the  blood-stream  from  generalized  infection  or 

^  Brit.  Med.  Jour.,  1906. 


VACCINES    IN    GENERAL    .NFECTIONS  64I 

excessive  autoinoculation.  It  reduces  what  may  bid  fair  to  become 
a  generalized  infection  into  a  localized  process.  The  persistence  of 
such  infections  after  surgical  operation  in  many  cases  is  from  failure 
to  recognize  that  the  localization  of  an  infectious  process  may  he  the  reason 
for  its  chronicity;  that  the  body,  through  local  conditions,  not  only  has 
lost  the  power  of  efficient  attack  against  the  invading  bacteria,  but  for 
the  same  reason  lacks  the  stimulus  which  it  requires  for  the  elaboration 
•of  protective  substances.  //  should  no  longer  he  considered  that  the 
surgeoii's  work  is  ended  when  he  lays  down  the  knife,  or  when  he,  hy 
various  appliances,  secures  complete  rest  to  the  affected  part;  he  must 
further  furnish  the  hacterial  stimulus  which  his  measures  have  eliminated, 
which  shall  so  act  upon  the  immunizing  mechanism  that  elaboration 
of  specific  protective  substances  shall  take  place.  Furthermore,  by  the 
proper  treatment  of  the  focus  of  infection,  as  previously  indicated,  the 
surgeon  shall  make  it  possible  for  the  blood-stream,  with  its  protective 
substances,  to  come  into  destructive  action  on  the  bacteria  in  the  focus. 
The  question  of  using  bacterial  vaccine  in  cases  of  generalized  in- 
fections ought  not  to  be  prejudged,  although  it  would  appear  that  the 
addition  of  toxic  material  in  the  way  of  vaccine  might  merely  increase 
the  toxemia  of  the  patient  without  having  any  effect  in  producing  an 
increase  in  his  power  to  cope  with  disease.  We  must  realize  that  in 
general  septicemia,  and  in  diseases  such  as  typhoid  fever  and  pneumonia, 
we  have  a  condition  of  continuous  autoinoculation;  that  is,  the  bacteria 
are  either  growing  in  the  blood  or  being  continuously  sent  forth  into  it 
from  foci  wdiich  are  in  direct  communication.  We  may  conceive  that 
in  these  cases  a  struggle  is  taking  place  largely  in  the  blood-stream, 
and  that  the  total  efficiency  of  the  immunizing  mechanism  is  receiving 
its  fullest  stimulus  to  the  formation  of  antibodies,  and  that  they  are  being 
applied  in  an  absolutely  unobstructed  manner  against  the  invading 
bacteria.  It  would  seem  here,  then,  that  the  only  indication  would  be 
to  stimulate,  so  far  as  possible,  the  immunizing  mechanism  to  increased 
production  of  antibodies  in  those  cases  in  which  there  is  an  unsatisfactory 
immunizing  response.  There  is  no  question  in  these  cases  but  that  the 
autoinoculating  stimulus  to  the  protective  mechanism  is  sufficiently 
great,  but  it  is  possible  that  it  is  not  efficiently  applied.  As  Wright  puts 
it,  "if  the  supposition  is  correct 'that  protective  substances  are  produced 
by  the  cells  at  the  seat  of  inoculation,  it  would  seem  that  the  conditions 
for  successful  immunization  must  be  less  favorable  when  vaccine  is 
injected  into  the  blood-stream  than  when  it  is  injected  subcutaneously." 
When  injected  into  the  circulation,  vaccine  comes  into  contact  with  the 
connective-tissue  cells  only  after  it  has  been  diluted  by  the  whole  circu- 

41 


642  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

lating  blood.  When  subcutaneously  inoculated  directly  into  the  tissues, 
vaccine  is  applied  in  a  concentrated  form.  He  states  that  it  would, 
therefore,  not  be  irrational  to  assume  a  possible  advantage  in  these 
cases  from  inoculation  of  vaccine.  To  the  objection  that  vaccine 
inoculation  might  aggravate  intoxication,  Wright  suggests  that  there  is 
reason  to  believe  that  the  vaccine  injected  is  probably  for  a  certain  length 
of  time  held  back  in  the  tissues  and  not  taken  into  the  blood-stream. 
In  favor  of  this  is  the  local  toxic  reaction  at  the  point  of  inoculation, 
which  may  be  characterized  by  redness,  swelling,  and  tenderness,  and 
which  makes  its  appearance  within  a  few  hours  after  the  injection  of 
vaccine;  and  also  the  belief  that  there  is  a  local  elaboration  of  bacterio- 
tropic  substances  at  the  point  of  inoculation,  a  belief  which  has  for  its 
basis  considerable  suggestive  evidence. 

Wright  reasons  further  that,  if  it  is  a  fact  that  the  vaccine  is  held 
back  in  the  tissues,  the  injection  of  the  same  amount  of  vaccine  in 
the  tissues  will  produce  less  intoxication  than  the  same  amount  injected 
into  the  blood-stream. 

To  whatever  conclusions  theoretic  considerations  may  lead  one, 
the  fact  remains  that  by  means  of  bacterial  vaccine  in  septicemic  cases, 
in  spite  of  the  fact  that  the  blood  is  the  recipient  of  continual  auto- 
inoculations,  nevertheless,  it  is  found  that  by  judicious  injection  of  vac- 
cine at  proper  intervals  and  in  proper  dosage  it  is  possible  to  produce  an 
immunizing  response  on  the  part  of  the  patient  as  registered  by  opsonic 
index  determinations.^ 

Additional  evidence  has  been  furnished  by  E.  C.  Rosenow,^  in  a 
study  of  14  cases  of  endocarditis,  mostly  due  to  the  pneumococcus.  He 
found  that  in  the  early  part  of  the  disease  the  opsonic  index  was  generally 
maintained  at  a  high  level,  and  at  this  stage  vaccine  had  apparently 
very  little  effect  in  producing  a  rise  in  the  opsonic  power.  In  the  later 
stages  of  the  disease,  however,  when  the  patient's  condition  was  poor, 
and  the  index  was  found  to  be  far  below  normal,  injection  of  vaccine  was 
followed  by  a  rise  in  the  opsonic  power  and  also  in  the  number  of  leuko- 
cytes. These  changes  were  associated  with  a  drop  in  temperature 
and  definite  improvement.  In  line  with  this  definite  laboratory  evi- 
dence we  have  the  clinical  observations  of  Thompson,^  in  which  he 
reports  the  study  of  7  cases,  all  treated  by  vaccine  derived  from  organ- 
isms cultivated  in  each  case  from  the  patient's  blood.  Three  cases  re- 
covered and  4  died.     In  2  of  the  fatal  cases  he  states  the  effect  of  the 

^  Lancet,  November  2,  1907,  Chart  15,  Chart  14,  etc. 
^  Trans.  Path.  Soc,  December  i,  1908. 
^  Amer.  Jour,  Med.  Sci.,  August,  1908. 


INDICATIONS   FOR  VACCINES  643 

vaccine  was  striking,  but  only  temporarily  beneficial;  in  2  others  the 
benefit  was  slight,  but  demonstrable.  In  the  others,  immediate  and 
continued  improvement  followed  the  use  of  vaccine.  Taken  in  connec- 
tion with  Rosenow's  and  Wright's  observations,  Thompson's  experiences 
would  suggest  the  efficiency  of  vaccine  in  raising  the  opsonic  power  of 
the  blood  even  in  generalized  infections. 

Summary  of  Indications  for  Vaccine. — The  exhibition  of  vac- 
cine we  have,  therefore,  found  to  be  indicated,  first,  in  localized  infections; 
second,  in  infections  which,  by  various  procedures,  have  been  tendered 
local  in  character;  third,  in  infections  subject  to  intermittent  auto- 
inoculation  which  cannot  be  checked;  fourth,  we  have  considered  the 
question  of  their  indication  in  generalized  infections;  in  other  w^ords, 
where  the  blood-stream  is  subject  to  continuous  auto-inoculation. 

Guidance  to  Correct  Dosage. — Vaccine  is  a  poison,  and  we  must 
in  our  use  of  it  consider  it  to  be  such  first  and  last.  It  has  absolutely 
no  resemblance  in  its  constitution  or  its  mode  of  action  within  the  body 
to  antitoxins,  such  as  diphtheria  antitoxin.  In  consideration  of  its 
being  a  poison  or  a  toxin,  we  have  at  once  a  decided  reason  for  careful 
consideration  of  the  dosage  that  we  should  use  in  treatment.  That  it  is, 
when  properly  used,  a  powerful  factor  in  control  of  some  diseases  is 
beginning  to  be  generally  recognized.  That  it  is  also  equally  powerful 
in  doing  harm  is  realized  by  the  few  who,  by  inordinate  dosage,  have 
produced  unfortunate  results,  and  to  those  within  whose  observations 
these  cases  have  come.  That  killed  bacteria  can,  when  injected  into 
the  normal  individual,  produce  nausea,  malaise,  rigors,  vomiting,  etc., 
and  localized  inflammatory  condition  at  the  point  of  inoculation,  the 
extensive  experience  of  Wright  in  protective  typhoid  inoculation  has 
clearly  shown.  In  other  words,  the  injection  of  bacterial  poison  may 
produce  the  same  train  of  symptoms  as  living  bacteria  of  the  same 
sort. 

It  is  well  known  that  a  dose  of  vaccine  containing  100,000,000  killed 
staphylococcus  pyogenes  aureus,  when  injected  into  a  patient  suffering 
from  furunculosis,  will  commonly  be  followed  by  improvement  in  the 
local  conditions  during  the  next  twenty-four  hours.  It  is  quite  as  well 
known  that  a  dosage  of  500,000,000  of  the  same  organism  in  a 
similar  case  will  commonly  be  followed  by  local  exacerbations  in  the 
furuncles  already  present,  and  very  probably  will  be  followed  by  the 
development  of  new  lesions.  Temperature  and  generalized  symptoms 
may  or  may  not  be  produced.  It  is  further  well  known  that  if,  in  a 
patient  suffering  from  pulmonary  tuberculosis,  a  dose  of  tuberculin  of 
Jg-  c.  mm.  O.  T.  is  given  subcutaneously,  it  is  apt  to  be  followed  by  a 


644  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

febrile  reaction  in  the  subsequent  few  hours,  associated  with  signs  of 
increased  activity  in  the  focus  of  disease.  The  injection  of  this  dosage 
of  tuberculin  in  an  uninfected  individual  is  without  constitutional  effect. 
The  same  may  be  said  about  the  injection  of  killed  staphylococci  in 
case  the  patient  is  not  infected. 

From  these  facts  it  would  appear  that  the  effect  produced  hy  these 
agents  is  not  primarily  due  to  the  amount  of  toxin  they  contain,  otherwise 
we  should  have  produced  the  same  symptoms  in  normal  individuals. 
Rather,  it  would  appear  to  be  that  the  exacerbations  of  the  infected  in- 
dividuals are  due,  not  to  the  inherent  toxic  power  of  the  dose  employed, 
but  to  some  effect  which  it  exerts  only  when  the  organism  is  infected 
with  an  organism  corresponding  to  that  used  in  the  vaccine.  It  has. 
been  suggested  by  some  who  favor  the  use  of  large  doses  of  vaccine  in 
generalized  infections  that  in  the  vaccine  injected  we  have  only  an  in- 
finitesimal addition  to  the  toxic  material  in  the  body,  compared  to  that 
represented  by  the  living  organisms  growing  therein.  If  such  inoculum 
could  be  added  into  the  midst  of  the  actual  focus  of  disease,  it  is  con- 
ceivable that  the  effect  would  be  of  very  slight  degree,  but  the  sequence 
of  events  following  injections  of  tuberculin  and  staphylococcic  vac- 
cines, and,  in  fact,  any  others,  indicates  clearly  that  in  correspondingly 
infected  individuals  there  is  an  effect  produced  which  is  absolutely 
out  of  proportion  to  the  amount  of  the  inoculum,  and  that  this  effect 
represents  a  temporary  breaking  down  of  the  patient's  resistance  to 
the  infection  is  clearly  indicated  by  the  exacerbation,  local  and  general, 
that  frequently  takes  place.  It  is  impossible  to  conclude  otherwise 
than  that  in  generalized  infections,  as  in  the  localized  or  in  pulmonary 
tuberculosis,  we  must  apply  the  same  rule  that  in  the  use  of  excessive 
dosage  of  vaccine,  in  spite  of  the  fact  that  it  is  infinitesimal  compared  with 
the  toxin  within  the  body,  we  nevertheless  will  derive  a  lowering  of  the 
patient's  resistance  to  the  living  organisms  in  the  body.  In  other  words, 
the  injection  of  vaccine  in  already  infected  patients  has  a  profound  effect 
upon  the  physiologic  mechanism  of  immunity  which  is  disproportionate 
to  the  amount  of  vaccine  injected  when  compared  with  the  amount  of  toxin 
and  living  bacteria  in  the  body. 

We  have  further  practical  reasons  for  seeking  sufficient  guidance  for 
the  giving  of  vaccine,  particularly  of  tuberculin,  in  the  unfortunate  results 
which  follov/ed  the  use  of  tuberculin  when  first  it  was  offered  by  Koch. 
The  effect  which  tuberculin  might  have  in  inducing  an  immunizing 
response  on  the  part  of  the  organism  was  not  considered.  The  con- 
trolling idea  in  this  first  application  of  tuberculin  in  treatment  was  that 
the  effect  was  exerted  in  the  breaking  down  and  the  discharge  of  the 


ELISION    OF    THE    NEGATIVE    PHASE  645 

tuberculous  focus  in  the  lung.  In  other  words,  tubercuKn,  as  originally 
used,  was  an  excellent  example  of  toxic  therapeutics.  The  effect  was 
not  only  to  produce  a  disintegration  in  the  focus  of  disease,  but,  as 
would  be  expected,  the  tendency  to  the  spread  of  disease  was  quite  as 
prominent  as  its  effect  upon  the  localized  focus.  It  is  perfectly  clear 
now  that  excessive  dosage  was  used  at  that  time,  that  it  lowered  the 
patient's  resistance,  and  was  responsible  for  the  serious  consequences. 
Tuberculin  was  for  a  long  time,  therefore,  under  a  ban  as  a  therapeutic 
measure. 

By  measuring  the  production  of  the  agglutinins  following  typhoid 
inoculation  Wright  found  that,  according  as  the  dosage  was  increased 
or  diminished,  the  latent  period  w^hich  elapsed  before  the  appearance 
of  agglutinins  in  the  blood  was  likewise  increased  or  diminished.  That, 
in  so  far  as  the  dose  was  increased  and  the  latent  period  consequently 
prolonged,  the  constitutional  symptoms  were  also  more  marked  and 
more  prolonged.  He  found  that  large  doses  might  induce  much  toxic 
reaction,  where  smaller  doses  might  produce  no  reaction.  That  in  the 
case  of  small  doses  the  response  in  the  production  of  agglutinating 
power  might  be  achieved  in  a  periqd  of  a  few  hours.  He  found  that 
by  measuring  the  phagocytic  power  of  the  blood  after  inoculation,  the 
same  sequence  of  events  took  place — aggravation  of  symptoms  before 
the  rise  of  the  phagocytic  power,  disappearance  of  symptoms  asso- 
ciated with  increase  in  the  phagocytic  power,  and  that  the  contmuance 
of  the  low  phagocytic  power,  and  the  aggravation  of  symptoms  as- 
sociated, were  more  marked  according  as  the  dosage  was  increased; 
that  when  minute  doses  of  vaccine  were  injected  there  might  follow  an 
elision  of  the  phase  of  diminished  phagocytic  power,  an  immediate  rise 
taking  place  instead.  In  other  words,  he  was  able  to  show  that  it  was 
possible  to  secure  a  protective  response  without  any  antecedent  period  of 
lowered  resistance.  He  was  further  able  to  show  that  a  condition  of 
decided  clinical  improvement,  following  the  use  of  appropriate  doses  of 
vaccine  in  staphylococcic  and  other  infections,  could  be  obtained  with- 
out any  antecedent  period  of  serious  aggravation  and  symptoms.  It  had 
pre\iously  been  generally  accepted  that  immunizing  response  following 
vaccine  could  not  be  efficient  unless  toxic  symptoms  were  induced.  The 
keynote,  therefore,  of  Wright's 'method  of  giving  bacterial  vaccine  is  to 
be  found  in  his  desire  for,  and  achievement  of,  an  adequate  response  \Aith- 
out  an  antecedent  period  of  toxemia  and  the  dangers  which  we  have  see 
to  be  attendant  upon  it.  He  has  taken  for  his  guide  the  phagocytic 
power  of  the  blood,  as  registered  by  the  opsonic  index,  and  has  endeavored, 
by  the  proper  dosage  of  vaccine  and  proper  interval  between  dosage,  to  secure 


646 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


adequate  immunizing  response,  as  registered  by  an  elevated  phagocytic 
power,  and  to  eliminate,  by  carefully  selecting  his  dosage,  the  induction  oj 
any  protracted  period  of  subnormal  phagocytic  power  with  its  attendant 
toxic  symptoms. 

The  knowledge  that  it  is  possible  to  secure  an  adequate  immuniz- 
ing response  on  the  part  of  the  body  from  the  inoculation  of  bacterial 
vaccine,  without  the  previous  induction  of  symptoms  of  toxemia,  and 
that,  by  consistently  increasing  the  dosage  of  vaccine,  likewise  guarding 
ourselves  against  such  toxic  symptoms,  we  may  maintain  the  protective 
mechanism  at  a  high  level  of  efficiency  correlated  with  improvement 
and  final  cure  of  the  disease  process,  is  derived  absolutely  and  entirely 
from  the  study  which  Wright  has  made  of  the  body  reaction  against 
infection,  and  subsequent  to  inoculation,  by  means  of  the  opsonic  index. 


TUBERCUIO- 
OPSONIC 


INDEX 

1-8 

1-6 

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1-4 

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2001, 

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r,G 

RM. 

^ 

IV 

1-2 

V 

i 

^ 

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NORMAL  10 

> 

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04 

OCT. 

3 

4 

5 

6 

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15  1 

Fig.  214. — Opsonic  Curve  Illustrating  the  Variations  in  the  Opsonic  Index  of  the  Blood  Follow- 
ing Inoculation  (A.  E.  Wright,  Lancet,  igoy,  1218). 


In  the  exhibition  of  vaccines,  it  is  the  aim  to  induce  the  body  to  pro- 
duce at  the  proper  time  specific  antibacterial  substances  by  the  use  of 
such  doses  of  killed  bacteria  as  suffice  to  raise  and  maintain  the  opsonic 
power  of  the  blood  above  normal. 

In  order  to  arrive  at  a  scheme  to  bring  this  about,  it  is  necessary, 
in  the  first  place,  to  study  the  effect  of  a  single  dose  of  vaccine  in  producing 
an  immunizing  response.  Wright  has  taken  arbitrarily  the  opsonic  in- 
dex to  register  the  variations  in  the  content  of  the  blood  in  antibacterial 
substances  for  various  and  good  reasons. 

In  Fig.  214  is  shown  a  curve  representing  daily  variations  in  the 
phagocytic  power  of  the  blood,  as  registered  by  opsonic  index  deter- 


minations, in  a  case  of  tuberculosis  after  an  inoculation  of 


1 
2000 


mg. 


of 


THE    INDEX    AFTER    INOCULATION  647 

tuberculin  R.  This  curve,  while  not  typical,  illustrates  a  certain  se- 
quence of  events  in  the  production  of  opsonins  which  will  follow  the 
inoculation  of  any  vaccine  if  given  in  suflEcient  dosage. 

At  the  start  we  have  two  opsonic  indices,  which  represent  a  low 
normal  phagocytic  power,  consistent  with  that  to  be  found  in  chronic 
localized  tuberculosis.  Immediately  following  inoculation  there  is 
recorded  a  slight  rise  in  the  phagocytic  power,  which,  though  in  any 
case  possibly  due  to  error  in  estimation,  occurs  so  frequently  that  it  may 
have  some  significance.  It  is  possible  that  it  represents  an  immediate 
response  to  the  stimulus  furnished  by  the  absorption  of  a  minute  amount 
of  the  inoculum.  A  very  important  feature  is  the  marked  decrease  in 
phagocytic  power  which  continues  low  until  the  third  day.  This  per- 
iod of  diminished  phagocytic  power  constitutes  the  negative  phase,  and 
represents  a  period  in  which  the  phagocytic  defense  to  the  tubercle 
bacillus  is  obviously  weakened.  Following  this  negative  phase  comes 
a  wave-like  increase  in  the  phagocytic  power,  registered  by  a  consider- 
ably and  continuously  elevated  opsonic  index.  During  this  period, 
termed  by  Wright  the  positive  phase,  the  offense  which  the  phagocytes 
are  able  to  offer  should  be  at  its  best.  The  next  feature  to  be  noted  is 
the  gradual  sinking  away  of  the  opsonic  power,  followed  subsequently 
by  a  gradual  rise  to  a  condition  somewhat  slightly  more  elevated  than  at 
the  start. 

In  describing  the  features  of  this  curve,  Wright  terms  the  negative 
phase  the  ebb,  the  positive  phase  the  flow,  the  subsequent  decline  as 
the  back  flow,  and  the  final  condition,  in  which  the  curve  is  slightly 
more  elevated  than  at  the  start,  he  terms  the  sustained  high  tide  of 
immunity.  The  form  of  the  curve  produced,  and  c'onsequently  the 
sequence  of  events  in  the  immunizing  response,  depends  on  the  dosage 
of  vaccine  injected.  If  the  dose  be  small,  that  is,  insufficient  perhaps  to 
produce  clinical  improvement,  there  may  be  an  immediate  rise  in  the 
opsonic ,  index  without  any  preceding  fall  or  negative  phase.  The 
positive  phase  or  increased  phagocytic  power  under  these  conditions, 
however,  will  be  of  short  duration,  a  few  hours  perhaps,  and  the  height 
of  the  rise  may  not  be  very  great.  If  a  larger  dose  be  given,  that  is,  a 
dose  Avhich  produces  a  satisfactory  immunizing  response,  as  would  be 
consistent  with  improvement  in  the  condition  of  the  patient,  a  sequence 
of  events  similar  to  Fig.  214  may  be  obtained;  that  is,  there  will  be  a 
fall  for  a  longer  or  shorter  time,  followed  by  a  rise  of  the  phagocytic  power 
above  normal,  and  then  a  gradual  fall  again.  The  effect  of  an  exces- 
sive dose  of  vaccine,  that  is,  a  dose  of  sufficient  size  to  produce  toxic 
symptoms,  would  be  to  induce  an  immediate  fall  in  the  phagocytic 


648  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

power  and  a  more  or  less  continued  depression,  depending  on  the  size  of 
the  dose.  The  continuation  of  this  phase  of  depression  may  be  for  a 
number  of  days.  If  no  further  inoculation  is  given,  there  may  occur  a 
spontaneous  recovery  of  opsonic  power. 

Wright  states^  that,  where  an  excessive  dose  of  vaccine  has  been 
given,  a  reinoculation,  as  soon  as  constitutional  symptoms  have  dis- 
appeared, of  a  minimum  dose  of  vaccine  would  practically  always  re- 
sult in  a  desirable  rise  in  the  phagocytic  power.  The  changes  in  the 
phagocytic  power  of  the  blood-stream  induced  by  inoculation,  as  above 
sketched,  will  apply  to  changes  which  will  be  produced  in  the  case  of  the 
normal  individual  or  one  subject  to  chronic  localized  infectious  dis- 
ease. The  same  law  of  the  sequence  of  negative  and  positive  phase  holds 
also  in  generalized  infections,  but  the  use  of  sufficient  dose  to  induce  a 
persistence  of  negative  phase  is,  as  we  shall  see  later,  a  dangerous 
procedure. 

It  is  obviously  desirable  in  treatment  to  maintain,  for  as  long  a 
period  as  possible,  a  high  level  of  phagocytic  resistance.  The  proper 
time  for  repeating  inoculations  would  naturally  be  at  the  time  when 
the  phagocytic  power  is  falling,  marking  the  end  of  the  positive  phase. 
A  negative  phase  of  short  duration  is  commonly  followed  by  a  positive 
phase  of  correspondingly  short  duration  and  slight  elevation.  An  ac- 
centuated negative  phase  of  moderate  duration,  say,  thirty-six  hours, 
may  be  followed  by  a  positive  phase,  lasting  several  days.  An  excessive 
dose  may  be  followed  by  merely  a  prolonged  negative  phase;  hence  the 
dose  is  an  extremely  important  factor. 

A  repetition  of  the  condition  repeated  in  Fig.  214  is  desirable.  To 
produce  this,  inoculations  must  be  given  at  the  end  of  the  positive 
phase.  If  the  inoculations  are  given  too  frequently,  the  effect  is  to  pro- 
duce a  partial  failure  in  response  and  an  elision  of  a  portion  of  the  posi- 
tive phase.  It  is  impossible,  by  frequent  inoculation  of  tuberculin, 
superimposing  one  dose  upon  another,  to  produce  a  continuous  increase 
in  the  opsonic  power.^  Each  inoculation  must  be  treated  as  an  independ- 
ent event,  and  should  be  followed  by  another  inoculation  as  soon  as  its 
effect  is  wearing  off. 

Correlation  of  These  Variations  with.  Clinical  Symptoms. 
— It  does  not  matter,  for  practical  purposes,  whether  the  opsonic  index  is  or 
is  not  a  measure  of  the  protective  response  to  inoculation,  if  it  can  be 
shown  that  it  corresponds  in  its  rise  and  in  its  fall  to  conditions  of  im- 
provement and  aggravation  in  the  clinical  symptoms  of  the  patient  and 

*  Lancet,  August  24,  1907,  p.  493. 

^  Wright,  Studies  in  Immunization,  p.  273. 


VARIATIONS    OF    OPSONIC   INDEX 


649 


in  the  activity  or  non-activity  of  the  focus  of  disease.     The  correlation 
between  the  chnical  symptoms  and  the  condition  of  the  opsonic  power 


of  the  blood  has  been  definitely  shown  as  follows:  First,  in  cases  of 
chronic  localized  staphylococcic  and  tuberculous  infections  we  have 
seen  that  the  opsonic  power    as   against  the  infecting  organism  is  in- 


650  THERAPEUTIC    BIMUXIZATIOX    AND    VACCINE    THERAPY 

variably  low.  Secondly,  as  a  result  of  thousands  of  opsonic  obser- 
vations, Wright  states  that  he  has  satisfied  himself  that  in  all  infections 
a  low  opsonic  index  is  correlated  with  an  unsatisfactory  clinical  con- 
dition, while  a  high  opsonic  index  is  correlated  with  a  clinical  condition 
which  shows  improvement  for  the  time  being.  Exception  to  this  is 
found  to  be  occasional,  and  is  accounted  for  by  the  supposition  that 
the  lack  of  improvement  is  due  to  a  walled-off  condition  of  the  focus  of 
disease,  and  to  the  impossibility  of  the  circulating  blood  coming  thor- 
oughly in  contact  with  the  infecting  organisms. 

Hektoen  states^  that  in  the  early  stages  of  pneumonia,  diphtheria, 
and  erysipelas,  when  the  symptoms  are  most  pronounced,  we  have  a 
condition  of  negative  phase  or  lowered  opsonic  power,  and  that  when  the 
symptoms  begin  to  subside,  such  subsidence  is  associated  with  a  rising 
opsonic  power.  This  variation  also  applies  to  the  streptococcus  in 
scarlet  fever.  In  fatal  cases  of  pneumonia  the  opsonic  curve  may  not 
recover  from  its  primary  depression,  but  sinks  lower  and  lower.  He 
refers  to  the  clear  and  close  association  between  recovery  and  the  wave- 
like rise  of  opsonin,  and  to  the  similar  correlation  of  improvement  in 
symptoms  and  conditions  associated  with  a  rise  in  opsonic  power  fol- 
lowing immunization  by  \'accine. 

Recognizing  in  the  negative  phase  following  inoculation  a  phase 
of  lowered  resistance,  and  in  the  positive  phase  a  period  of  increased 
resistance;  it  is  the  endeavor,  by  means  of  vaccines,  to  secure,  associated 
with  as  brief  a  period  as  possible  of  lowered  phagocytic  power,  as  pro- 
longed a  period  as  possible  of  elevated  phagocytic  power. 

These  facts  lead  us  to  the  conclusion  that  the  negative  phase,  as 
measured  by  the  opsonic  index,  in  that  it  is  associated  with  aggrava- 
tion of  the  disease  or  at  least  a  condition  of  stasis,  is  a  thing  to  be  avoided, 
and  that  any  therapeutic  measure  which  may  induce  such  a  condition 
might  be  dangerous  to  the  life  of  the  patient  in  some  cases  or  inimical 
to  progress  toward  recovery. 

Opsonic  determinations  following  the  use  of  vaccine  in  the  treat- 
ment of  infectious  diseases  have  shown  that,  associated  with  the  negative 
opsonic  phase,  may  be  an  aggravation  of  symptoms,  such  as  might  be 
expected  to  supervene  if  the  phagocytic  resistance  were  lowered  for 
any  length  of  time.  We  see  in  furunculosis,  following  the  inoculation 
of  a  large  dose  of  vaccine,  indications  of  this  aggravation  during  the 
period  in  which  the  opsonic  index  is  subnormal,  in  the  fact  of  increase  ] 
tenderness,  discharge,  and  the  development  of  fresh  furuncles.  In 
the  case  of  gonorrheal  joints,  associated  with  the  negative  phase  after 

^  Cleveland  Med.  Jour.,  May,  1909. 


CLINICAL    USE   OF   THE   INDEX  65 1 

inoculation,  we  find  commonly  increased  pain,  tenderness,  and  pos- 
sibly swelling  in  the  joint,  and  in  some  cases  febrile  reaction.  In  bladder 
infections  following  inoculation  we  may  obtain  increased  pain,  in- 
creased frequency  of  micturition,  and  increased  cloudiness  of  the  urine; 
in  pulmonary  tuberculosis,  temperature  and  focal  signs  of  acti\ity. 
Associated  with  the  oncoming  of  the  positive  phase  of  increased  phago- 
cytic power  in  all  these  diseases  we  see  amelioration  in  signs  and  symp- 
toms. Where  toxic  doses  of  vaccine  are  given,  we  may  obtain  long  per- 
iods of  aggravation  of  symptoms,  and  associated  with  them  continuously 
low  opsonic  power.  In  general,  we  may  consider  that  the  production 
of  any  period  of  lowered  opsonic  power  as  a  period  of  retrogression, 
and  as  a  period  of  progress  that  of  elevated  opsonic  power. 

We  have  reason,  therefore,  to  so  grade  our  doses  of  vaccine  that  neg- 
ative phase  will  be  of  as  short  duration  as  possible  consistent  with  a 
positive  phase  of  sufi&cient  degree  and  duration  to  be  consistent  wdth 
improvement.  It  has  been  Wright's  method,  therefore,  in  using  bac- 
terial vaccines,  to  guide  his  dosage  by  frequent  opsonic  determinations, 
in  order,  first,  to  avoid  prolonged  negative  phase,  and,  second,  to  deter- 
mine the  time  when  the  opsonic  power  shows  evidence  of  falling,  in  order 
to  derive  indications  for  further  dosage.  If  he  finds  that,  twenty-four 
hours  after  inoculation,  the  index  has  been  much  reduced,  he  considers 
that  a  smaller  dose  than  the  one  given  would  have  been  appropriate. 
If  he  finds  that  twenty-four  hours  after  inoculation  the  index  has  been 
raised,  and  if  after  ten  days  the  index  has  fallen  to  the  point  at  which 
it  stood  before  inoculation,  in  the  absence  of  constitutional  disturbance 
on  the  part  of  the  patient,  he  considers  that  a  larger  dose  could  have  been 
administered.  The  ideal  dosage  is  one  which  will  induce  a  slight  initial 
fall  after  inoculation,  and  after  from  seven  to  ten  days  will  be  found  to  be 
higher  than  it  was  at  the  outset.  The  duration  of  the  initial  fall  de- 
pends, of  course,  on  the  dosage,  and  should  not  be  longer  than  from 
twenty-four  to  forty-eight  hours.  The  question  of  increasing  the 
dosage  is  decided  entirely  upon  the  manner  of  the  immunizing  response 
obtained.  Wright's  rule  is  never  to  increase  to  a  larger  dose  until  one 
fails  to  obtain  a  satisfactory  elevation  in  the  opsonic  index  with  the  dose 
used.  The  question  of  superimposing  one  dose  upon  another  before 
the  opsonic  index  has  begun  to  show  signs  of  falling  is  an  important  one. 
It  would  appear  at  first  glance  to  be  best  to  derive  the  full  effect  from 
the  past  dose  before  injecting  the  next,  and  this  seems  to  be  actually 
the  case.  Wright  has  shown  that,  in  a  case  of  tuberculosis,  it  is  impos- 
sible to  cause  a  cumulation  in  the  direction  of  a  positive  phase;  that  is, 
one  cannot,  by  injecting  tuberculin  frequently,  produce  a  gradually  in- 


652  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

creasing  opsonic  power.  ^  He,  therefore,  considers  each  inoculation  inde- 
pendently, and  does  not  attempt  to  produce  a  gradually  increasing  ele- 
vation in  the  opsonic  power. 

The  difficulty  of  obtaining  accurately  estimated  opsonic  indices, 
and  the  large  amount  of  time  necessary  for  their  correct  determination, 
has  rendered  it  desirable  to  find  some  more  simple  method  of  giving 
vaccine  than  that  based  on  the  determination  of  the  opsonic  index  as  a 
guide  in  every  case.  In  consideration  of  the  fact  that  the  opsonic 
index  has  a  definite  correlation  with  the  clinical  symptoms,  it  is  possible, 
in  those  cases  in  which  signs  and  symptoms  may  be  easily  observable, 
to  make  use  of  them  as  guides  to  dosage  of  vaccine.  In  the  case  of 
furunculosis  the  development  of  new  furuncles  and  their  continued 
aggravation  for  several  days  would  be  evidence  of  lowered  phagocytic 
power;  in  other  words,  of  a  pronounced  and  continued  negative  phase. 
It  may  be  taken  as  evidence  that  the  dosage  of  vaccine  was  too  large.  If, 
on  the  following  day  after  inoculation,  in  such  cases,  there  is  a  slight  ex- 
acerbation in  the  furuncles  already  present,  but  on  the  subsequent  day 
a  marked  improvement  and  a  continued  improvement  over  the  several 
following  days,  the  dosage  may  be  taken  as  correct.  In  the  case  of  a 
sinus  or  abscess,  a  marked  increase  in  the  discharge  may  indicate  the 
induction  of  a,  marked  negative  phase  from  too  large  dosage.  In  the 
case  of  an  ulcer,  the  increase  in  discharge  and  extension  may  mean  the 
same  thing.  In  the  case  of  a  gonorrheal  joint,  local  exacerbations  may 
continue  for  several  days,  and  in  such  a  case  the  dosage  has  been  too 
large.  In  the  case  of  bladder  infections,  we  may  take  pain,  frequency  of 
micturition,  the  condition  of  the  urine,  and  possibly  temperature,  as 
indications. 

In  glandular  tuberculosis  a  single  excessive  dose  may  or  may  not 
produce  increased  swelling  and  pain.  Such  walled-off  infections  are  not 
as  immediately  susceptible  to  lowered  resistance,  because  of  their  walled- 
off  condition,  and  because  the  conditions  in  the  focus  are  of  much  less 
antibacterial  efficiency  than  that  of  the  circulating  blood  in  an  un- 
treated case.  Where  a  series  of  excessive  doses,  however,  are  given, 
we  may,  after  a  long  time,  find  a  lack  of  progress,  or  in  extension  of  the 
process  to  other  glands,  that,  instead  of  increasing  the  patient's  resist- 
ance, we  have,  by  our  injections,  induced  a  condition  of  predominating 
negative  phase.  It  is  in  these  conditions  particularly  that  occasional 
opsonic  index  determinations  may  be  necessary  to  determine  whether 
or  not  our  dosage  is  successful  in  producing  satisfactory  phagocytic 
response.     In  fact,  in  this  type  of  case  the  opsonic  index  is  the  only 

^  See  Trans.  Med.  Chir.  Soc,  vol.  Ixxxix,  1906,  Chart  5. 


THE    SICKER    THE    PATIENT,    THE    SMALLER    THE    DOSE  653 

method  for  determining  whether  the  tubercuhn  used  is  of  satisfactory 
potency.  In  localized  infections,  therefore,  where  it  is  possible  to  ob- 
serve the  symptoms  and  conditions  following  vaccine,  we  are  able  at 
once  to  say  whether  or  not  our  dosage  is  efficient  or  harmful.  In  the 
treatment  of  generalized  infections,  such  as  the  septicemias,  and  in  ery- 
sipelas, cellulitis,  uterine  sepsis,  etc.,  infections  characterized  by  tem- 
perature and  generalized  symptoms,  much  more  care  is  necessary  in  using 
vaccine  than  in  the  localized  infections,  and  much  smaller  doses  must  be 
used,  with  the  idea  of  producing  an  immediate  positive  phase.  In  spite 
of  the  fact  that  the  opsonic  power  may  be  low,  and  that  the  amount  of 
vaccine  introduced  would  seem  infinitesimal  compared  to  that  already  in 
the  body,  it  is  impossible  to  conceive  that  large  doses  could  do  anything 
but  maintain  a  lowered  state  of  resistance.  We  know  that  a  minute  dose 
of  streptococcus,  for  instance,  of  5,000,000,  may  produce  in  septicemia  an 
immediate  elevation  in  opsonic  power.  We  further  know  that  such  an 
elevation  will  persist  for  but  a  few  hours  only,  hence  such  dosage  must 
be  repeated  more  frequently  than  if  larger  doses  were  given.  Hence 
in  septicemia  the  dose  should  be  repeated  every  day  or  more  often.  We 
cannot  afford  in  these  cases  to  diminish  the  phagocytic  power  or  other 
factors  in  resistance  even  for  a  few  hours,  because  during  that  time  the 
bacteria  will  find  conditions  more  suitable  for  unbridled  growth. 
In  infectious  processes  with  temperature,  a  drop  during  the  few  hours 
following  inoculation  would  indicate  that  the  dosage  used  was  not  harm- 
ful, while  a  rise  might  or  might  not  indicate  that  the  effect  was  toxic. 
Temperature  and  subjective  symptoms  appear  to  be  the  best  clinical 
guide. 

A  good  rule  to  follow  in  the  use  of  vaccine  is,  the  sicker  the  patient,  the 
smaller  the  dose  that  should  he  given. 

When  it  is  impossible  to  obtain  guidance  from  clinical  symptoms, 
as  in  tuberculous  glands,  as  to  the  dosage  necessary,  one  must  fall  back 
on  experience  in  giving  tuberculin  to  these  cases  under  guidance  of  the 
opsonic  index.  The  initial  dosage  should  be  so  small  that  symptoms  are 
out  of  question,  and  every  increase  should  be  likewise  minute  enough 
to  entirely  avoid  them. 

There  is  no  rule  as  to  the  period  that  is  to  elapse  between  doses. 
The  vaccinating  qualities  of  the  vaccine,  and  the  ability  of  the  patient 
to  respond  to  its  action,  are  variable  factors.  Hence  no  interval  has 
been  laid  down  as  the  proper  one.  A  minute  dose  which  may  produce  a 
rise  in  the  opsonic  power  almost  at  once  will  be  followed  by  a  brief 
positive  phase,  and  hence  rcinoculation  is  soon  necessary.  A  dosage 
might  be  arrived  at  which  could  be  repeated  every  four  hours,  everyday, 


654  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

or  less  often.  There  can  be  no  fixed  rule.  In  septicemia  and  like  con- 
ditions small  doses  must  be  used  and  hence  they  must  be  given  daily 
or  more  often. 

In  starting  inoculation  after  operative  procedures,  the  fact  that  the 
operation  has  induced  an  aiitoinoculation  should  be  borne  in  mind,  and 
no  vaccine  given  until  the  full  effect  of  it  has  worn  off.  In  carbuncle  two 
or  three  days  may  elapse,  in  tubercle  a  week  perhaps,  depending  on  the 
amount  of  autoinoculation  which  the  extent  of  the  surgical  procedures 
would  lead  one  to  suspect. 

Dangers  in  Overdosage. — It  is  obviously  most  desirable  in  the 
exhibition  of  vaccine  to  avoid  producing  anything  in  the  way  of  severe 
subjective  symptoms.  The  future  of  vaccine  therapy  will  be  much 
more  secure  if  satisfactory  results  can  be  achieved  without  production 
of  unpleasant  symptoms  immediately  following  inoculation.  We  may 
take,  of  course,  production  of  subjective  symptoms  as  danger-signals, 
that  the  dosage  is  producing  a  negative  phase  and  may  well  be  smaller. 
If  inoculation  be  given,  using  signs  of  intolerance  of  vaccine  as  a  guide,' 
there  must  be  reached  in  almost  every  case  treated  a  point  when  intoler- 
ance will  be  manifested.  The  so-called  clinical  method  of  giving 
vaccine  gradually  increases  the  dosage,  with  the  idea  of  securing  eventu- 
ally tolerance  to  large  doses  of  vaccine.  In  contrast,  the  method  that 
Wright  has  developed,  using  the  opsonic  index  as  a  guide,  does  not  in- 
crease the  dose  until  there  is  evidence  that  the  last  dose  has  not  been 
efficient  in  raising  the  opsonic  power  of  the  blood.  Increase,  there- 
fore, has  been  gradual.  During  five  months'  service  in  Wright's 
clinic,  at  St.  Mary's  Hospital,  the  writer  remembers  but  one  or  two 
instances  where  severe  subjective  symptoms,  focal  or  general,  were 
produced  by  inoculations.  In  over  600  cases  treated  by  the  writer  in 
the  past  two  years,  opsonic  index  determinations  have  not  been  user! 
as  a  guide  to  treatment.  The  initial  dose  has  always  been  sufficiently 
small  to  make  it  certain  that  no  serious  negative  phase  will  be  induced. 
The  doses  have  been  increased  gradually,  in  accordance  with  the  ex- 
perience gained  in  treating  cases  with  the  opsonic  index  as  a  guide, 
and  in  infections  other  than  localized  staphylococcic  there  has  been 
no  instance  in  which  intolerance  has  been  noted.  The  final  dosage 
of  tuberculin,  after  a  year's  treatment,  has  invariably  been  smaller' 
than  that  reached  after  a  like  period  by  those  using  the  clinical  method. 
The  results  have  been  satisfactory,  and  the  patients  in  all  cases  have 
continued  to  accept  treatment  without  any  fear  of  being  made  ill.  In 
the  case  of  furunculosis,  however,  it  has  been  the  custom  to  give  some- 
what larger  doses  than  those  calculated  not  to  produce  subjective  symp- 


DANGERS    OF    OVERDOSAGE  655 

toms,  as  it  appears  that  more  rapid  improvement  will  take  place  follow- 
ing a  dosage,  such  as  may  produce  temporary  exacerbation  without 
doing  the  patient  harm. 

Glandular  tuberculosis  is  noteworthy,  in  that,  even  though  pro- 
longed negative  phase  may  follow  a  tuberculin  injection,  there  may  be 
no  e\ddence  in  the  condition  of  the  patient  or  in  the  focus  of  disease 
that  such  is  the  case.  A  series  of  excessive  doses  may  be  thus  given 
over  a  long  period,  and  the  sum  total  of  the  effect  may  be  in  the  direc- 
tion of  reducing  the  patient's  resistance  instead  of  increasing  it.  In 
some  cases,  where  no  improvement  is  shown  from  month  to  month,  it 
is  impossible  to  determine  whether  or  not  the  scheme  of  dosage  has  been 
such  as  to  produce  a  heightened  opsonic  power  consistent  with  improve- 
ment. In  these  cases  the  opsonic  index,  occasionally  determined,  will 
indicate  as  to  whether  the  tuberculin  as  given  is  efficient. 

It  has  been  shown  by  Wright  and  others  that  excessive  doses  or  too 
frequent  dosage  induces  a  more  or  less  continuous  condition  of  negative 
phase  and  lack  of  resistance.  While  such  a  condition  might  not  be  of 
serious  import  to  the  life  of  the  patient,  in  glandular  tuberculosis,  in 
furunculosis,  or  in  strictly  localized  infections,  it  is  certainly  not  the 
case  where  bacteria  are  multiplying  in  or  gaining  entrance  into  the 
blood  through  autoinoculation.  It  is  perfectly  evident  that  if,  in  such 
cases,  the  ability  of  the  blood-stream  to  destroy  bacteria  is  lessened, 
there  will  be  offered  a  much  better  opportunity  for  living  bacteria  to 
exist  in  the  blood-stream  for  a  sufficient  length  of  time  to  be  transferred 
to  other  parts  of  the  body,  and  possibly  to  produce  new  foci  of  disease. 
In  addition  to  this,  the  size  of  the  autoinoculation,  that  is,  the  number 
of  bacteria  introduced  into  the  blood,  may  be  definitely  increased  on 
account  of  the  increased  activity  in  the  focus,  which  is  known  to  ac- 
company the  negative  phase  immediately  following  excessive  auto- 
inoculations.  This  stirring  up  of  the  focus  after  excessive  inoculation, 
and  its  effect  in  inducing  autoinoculation,  is  perfectly  well  illustrated 
in  pulmonary  tuberculosis  following  diagnostic  dosage  of  tuberculin. 
Here,  the  focal  signs  and  the  temperature  induced  can  mean  nothing 
else  than  that  bacteria  are  being  taken  in  excessive  numbers  into  the 
blood-stream.  In  pulmonary  tuberculosis,  the  harm  which  an  excessive 
dose  of  tuberculin  may  produce  is  evidenced  by  the  unfortunate  results 
which  occurred  following  the  first  use  of  tuberculin  after  its  discovery 
by  Koch,  and  since  that  time,  by  the  induction  of  generalized  tubercu- 
lous infections  and  the  production  of  other  foci  of  disease  following  its 
excessive  use. 

A  case  of  extensive  furunculosis  of   the  neck  of   several  months' 


656  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

duration  is  illustrative  of  the  harmful  effect  of  injudicious  dosage  of 
vaccine  in  localized  infections.  The  case  was  referred  to  the  writer  for 
decision  of  the  question  as  to  why  the  vaccine  as  injected  had  not  been 
followed  by  a  cure.  Patient  had  been  recei\ing  400,000,000  staphylo- 
coccus aureus  vaccine  daily  for  about  a  week,  and,  previous  to  this,  the 
same  dosage  had  been  given  every  two  or  three  days  for  a  month.  The 
condition  showed  no  improvement.  Following  the  writer's  suggestion, 
no  vaccine  was  injected  for  five  days.  Then  the  same  dosage  was  given 
and  repeated  four  days  later.  At  the  end  of  two  weeks  the  patient  was 
entirely  well,  and,  so  far  as  is  known,  has  since  remained  so.  This 
would  appear  to  be  clinical  e^ddence  of  a  more  or  less  continuous  nega- 
tive phase  produced  by  too  large  and  too  frequent  dosage,  and  of  its  result 
in  leading  to  chronicity  rather  than  to  recovery.  Such  cases  are  not 
serious  in  their  outcome,  but  their  frequent  occurrence  cannot  be  of 
any  advantage  to  the  welfare  of  vaccine  therapy  in  any  community. 

The  really  serious  results  of  overdosage  of  vaccine  would  appear  to 
be  in  the  generalized  infections  and  in  those  subject  to  autoinoculation. 
Here  the  maintenance  of  a  lowered  antibacterial  power  in  the  blood-stream 
may  most  certainly  be  conducive  to  unbridled  growth  of  bacteria  in  the 
blood,  and  to  the  induction,  in  acute  cases,  of  severe  toxemia.  In  septi- 
cemias, such  lowering  of  the  antibacterial  power  obviously  should  not 
be  produced  even  for  a  few  hours.  In  cases  subject  to  intermittent  auto- 
inoculation, excessive  dosage  of  vaccine,  occasionally  given,  might  con- 
ceivably do  no  harm,  but  if  given  sufficiently  often  to  cause  a  persistent 
lowering  of  the  antibacterial  power  of  the  blood,  although  conceivable 
that  the  patient  may  recover  in  spite  of  it,  he  cannot  recover  on  account 
of  it.  A  case  in  point,  indicating  probable  disastrous  results  from  over- 
dosage of  vaccine,  is  one  which  came  to  the  writer's  attention  after  it 
had  been  treated  for  over  a  month  with  injections  of  colon  vaccine. 
Following  appendectomy  a  discharging  sinus  persisted.  That  auto- 
inoculation was  taking  place  irregular  temperature  indicated.  For  some 
time  colon  vaccine  had  been  injected  every  few  days,  and  for  the  week 
before  the  patient  was  seen  by  the  writer,  inoculations  of  200,000,000 
organisms  had  been  gi\-en  approximately  every  four  hours.  It  was 
stated  that  the  idea  in  gi'ving  such  frequent  and  excessi\-e  dosage  was 
based  on  the  supposition  that  opsonins  are  produced  locally;  that  a 
localized  inflammatory  reaction  at  the  point  of  inoculation  is  indicative 
that  the  vaccine  is  effective  in  production  of  antibodies;  that  hence, 
the  more  local  reactions  that  are  produced,  the  greater  the  production  of 
antibacterial  substances. 

Without  discussing  the  fallacy  of  this  reasoning  it  may  be  stated  that 


A   CASE    OF    OVERDOSAGE  657 

the  patient  gradually  lost  ground,  became  emaciated,  and  finally  reached 
an  extremely  critical  condition.  Physical  examination  suggested  that 
the  condition  might  be  due  to  an  abscess  in  the  vicinity  of  the  diaphragm. 
Operation  revealed  that  there  was  no  such  condition.  Smears  on  agar 
were  made  from  the  blood  at  the  time  of  operation,  and  on  being  incu- 
bated showed  a  solid  growth  of  colon  over  the  whole  surface  of  the 
culture-medium.  The  patient  died  several  days  later.  In  the  absence 
of  any  evidence  of  local  condition  which  might  have  produced  death,  it 
is  to  be  assumed  that  it  was  due  to  colon  septicemia.  It  is  conceivable 
that,  just  antemortem,  it  would  be  possible  to  demonstrate  the  profusion 
of  bacterial  growth  in  the  blood  which  was  found  at  this  time,  which  was 
several  days  before  death.  The  writer  has  observed  the  bacterial  gro\Ath 
obtained  in  a  considerable  number  of  blood  cultures  in  the  past  ten  years, 
but  has  never  seen  or  seen  reported  any  such  profuse  growth  from  the 
few  drops  of  blood  which  could  be  absorbed  by  the  small  cotton  swab 
used  in  taking  the  culture  in  this  case.  It  is  the  belief  of  the  writer  that 
such  profuse  growth  is  only  consistent  with  conditions  of  the  blood- 
stream which  may  be  present  just  antemortem,  or  which  might  be 
produced  in  cases  where  the  antibacterial  power  of  the  blood  has  been 
artificially  reduced,  and  so  maintained,  by  inordinate  doses  of  correspond- 
ing vaccine.  In  consideration  of  what  has  already  been  said,  to  the  effect 
that  toxic  symptoms,  induced  by  large  and  frequent  dosage  of  vaccine 
in  septicemic  cases,  are  not  so  much  due  to  the  inherent  toxic  quality  of 
the  vaccine  itself,  as  to  its  effect  in  the  way  of  paralyzing  the  immunizing 
mechanism,  we  must  not  allow  ourselves  to  be  misguided  by  the  asser- 
tion that,  inasmuch  as  even  large  doses  are  infinitesimal  in  their  actual 
toxic  content  compared  with  the  amount  of  toxic  material  already 
in  the  body,  vaccine  can  be  given  with  impunity  in  cases  of  generalized 
infections.  As  has  already  been  stated,  there  is  no  reason  to  think 
that  large  doses  of  vaccine  in  septicemias  will  not  produce  and  main- 
tain the  same  lowering  of  the  patient's  resistance  that  we  have  seen  takes 
place  in  localized  infections,  such  as  furunculosis  and  carbuncle. 

In  treating  septicemic  cases,  a  scheme  of  dosage  that  will  induce  re- 
peated slight  elevations  of  the  opsonic  power,  without  pre\aous  nega- 
tive phase,  must  be  used.  Elision  of  negative  phase  is  possible  if  we  hold 
to  minute  dosage.  The  rise  in  opsonic  power  obtained  is  of  short  dura- 
tion. Hence  reinoculation  is  necessary  at  short  intervals.  The  same 
rule  holds  in  all  cases  subject  to  autoinoculation. 

The  size  and  frequency  of  dosage  depend  on  the  character  of  the 
autoinoculation:  small,  if  it  be  continuous  and  excessive,  as  indicated 
by  temperature  and  toxemia;  larger,  if  intermittent  and  less  in  amount. 

42 


658  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

The  rule  that  "the  sicker  the  patient  the  smaller  the  dose  of  vaccine" 
cannot  be  repeated  too  often  or  too  strongly  emphasized. 

Site  for  Inoculation. — That  commonly  used,  because  most  con- 
venient to  get  at,  is  the  upper  posterior  portion  of  the  arm.  The  back 
or  abdomen  is  quite  as  satisfactory,  but  cannot  be  reached  so  easily. 

The  probability  that  antibacterial  substances  are  produced  at  the 
point  of  inoculation  would  suggest  that  advantage  might  be  gained  by 
placing  the  inoculation  at  such  a  point,  in  relation  to  the  lesion,  that 
the  lymph-stream  may  at  once  carry  the  newly  formed  protective  sub- 
stances into  contact  with  the  bacteria  therein,  before  they  become  diluted 
by  the  whole  blood-stream.  Vv^right  states  that  by  thus  inoculating 
"up  stream,"  as  it  were,  better  results  have  been  obtained  in  certain 
cases  than  by  the  usual  method. 

I/Ocal  Reaction. — Inoculation  of  vaccine  derived  from  pyogenic 
organisms  and  some  others,  using  dosage  of  ser\iceable  proportions,  com- 
monly produces  at  the  point  of  injection  an  inflammatory  reaction.  This 
is  dependent  partly  upon  the  size  of  the  dose,  partly  on  the  condition  of 
sensitization  of  the  patient  to  the  poison  of  the  infecting  bacterium. 
Ordinary  therapeutic  doses  do  not  produce  a  reaction  in  the  case  of  in- 
dividuals uninfected  by  the  corresponding  organism.  In  infected  indi- 
\dduals  the  reaction  varies  somewhat  according  to  the  size  of  the  dose, 
As  the  patient  recovers  from  the  infection,  the  reaction  becomes  less 
marked  and  finally  may  not  appear  after  very  large  doses.  The  reaction 
consists  of  redness,  swelling,  tenderness  over  an  area  of  varying  size. 
It  may  involve  the  skin  of  the  whole  posterior  portion  of  the  upper  arm. 
Its  onset  is  commonly  within  a  few  hours  after  inoculation,  and  it  reaches 
a  maximum  within  thirty-six  hours.  If  the  inoculation  be  given  deeply, 
the  reaction  is  less  apparent.  Associated  with  a  marked  local  reaction, 
may  also  occur  a  focal  reaction,  manifested  by  increased  signs  of  activity 
in  the  lesion.  Experience  has  shown  that,  in  general,  those  cases  which 
develop  the  more  active  local  reactions  react  best  to  the  vaccine  in  their 
protective  response. 

These  local  reactions  are  specific.  They  do  not  appear  unless  the 
vaccine  used  is  derived  from  the  organism  that  is  the  infecting  agent. 
In  localized  infections  the  absence  of  reactions  after  a  moderate  dose 
indicates  that  the  vaccine  is  probably  not  the  proper  one;  in  other  words, 
the  diagnosis  of  the  actual  infecting  agent  is  in  error.  Exception  to  this 
rule  is  found  in  some  individuals  who  have  apparently  not  the  power  to 
react.  In  some  grave  septicemias  local  reactions  may  be  absent.  A 
properly  small  dose  in  septicemia  may  produce  only  the  slightest  local 
reaction,  or  none  at  all  if  injected  deeply. 


LOCAL  AND  FOCAL  REACTION  659 

Untoward  local  effects  are  rarely  seen.  It  is  conceivable  that  a  re- 
action might  be  so  acute  that  the  tissues  might  break  down.  This 
actually  occurred  in  one  of  the  writer's  cases.  Culture  from  the  pus 
proved  sterile.  The  vaccine,  which  had  been  used  in  treating  many 
patients  with  good  results,  also  proved  sterile. 

In  tuberculous  conditions  therapeutic  doses  of  vaccine,  if  injected 
deeply,  commonly  produce  no  demonstrable  local  reaction.  A  small, 
hard  nodule  may,  however,  develop.  If  injected  into  the  skin,  or  just 
below  it,  a  reaction  similar  to  that  of  von  Pirquet  may  be  produced. 
Local  reactions  have  not  been  prominent  in  cases  treated  by  the  writer. 

Skin  reactions,  in  that  they  appear  to  be  specific,  are  valuable  as 
indicating  whether  or  not  the  proper  vaccine  is  being  used,  and  their' 
intensity  indicates  to  some  degree  the  power  of  protective  response  of  the 
individual.  The  gradual  loss  of  ability  to  react  locally  to  increasing 
doses  may  mean  increasing  immunity  to  the  organism  in  question. 

!Focal  Reaction. — This  is  best  seen  in  the  treatment  of  furunculosis. 
If  the  dose  of  vaccine  be  of  sufficient  size,  associated  with  the  local  re- 
action and  the  negative  phase,  increased  tenderness,  possibly  swelling, 
increased  discharge,  and  possibly  a  new  lesion,  may  appear  at  the  seat 
of  infection.  In  pulmonary  tuberculosis  focal  reaction  consists  in  in- 
creased rales,  both  in  number  and  extent,  and  possibly  increased  ex- 
pectoration. 

In  gonorrheal  joints  a  dose  of  10,000,000  bacteria  may  be  followed  by 
increase  in  pain,  swelling,  and  tenderness  in  any  or  all  joints  affected. 
If  a  larger  dose  is  used,  the  symptoms  become  more  pronounced.  These 
focal  reactions  give  evidence  of  increased  activity  of  the  bacteria  in  the 
focus  of  infection.  The  period  in  which  they  develop  corresponds  to 
that  of  the  local  reaction,  and  to  the  phase  of  diminished  resistances, 
as  indicated  by  the  opsonic  index. 

Focal  reactions  are  made  use  of  in  diagnosis  of  pulmonary  tuberculo- 
sis, and  Irons  ^  has  made  use  of  the  focal  reaction  in  diagnosis  of  gonor- 
rheal joints.  In  some  cases  of  localized  tuberculosis  focal  reaction  may 
follow  a  dosage  of  -g-J-j,-  mg.  or  less  of  tuberculin,  and  thus  localizing 
diagnoses  may  sometimes  be  made. 

Preparation  of  Bacterial  Vaccine 

The  successful  application  of  bacterial  vaccine  in  the  treatment  of 
infectious  processes  depends  fundamentally  upon  a  properly  prepared 
and  constituted  vaccine.  There  is  required  for  the  production  of  such  a 
vaccine  a  well-equipped  laboratory,  separate   and  apart  from  routine 

*  Arch,  of  Int.  Med.,  igo8,  i,  p.  432. 


66o  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

pathologic  work,  kept  clean  and  as  free  as  possible  from  dust,  and  de- 
voted exclusively  to  the  purpose.  Test-tubes  and  other  glass  receptacles 
which  maybe  used  as  containers  at  any  stage  in  the  preparation  of  vaccine 
should  be  used  exclusively  for  these  purposes.  Animals  used  in  inocula- 
tion experiments  should  be  kept  apart  from  those  used  in  routine  patho- 
logic work.  Certain  special  apparatus  will  be  convenient,  and  will  later 
be  described.  Of  importance  equal  to  that  of  a  laboratory  is  the  use  of  a 
carefully  elaborated  technique,  which  shall  offer  every  possible  safeguard 
to  the  end  of  securing  vaccines  that  shall  be  accurately  standardized, 
sterile,  and  free  from  any  contaminating  growth. 

The  constitution  of  the  vaccine  is  suggested  by  the  commonly  ac- 
cepted definition,  which  is  as  follows:  The  bacterial  vaccine  is  a  sus- 
pension of  killed  bacteria,  which,  when  introduced  into  the  animal  body 
in  su'jjicient  dosage,  induces  an  elaboration  of  antibacterial  or  protective 
substances,  specific  in  their  action  against  the  variety  of  bacteria  injected. 
A  properly  constituted  vaccine  for  any  particular  case  is,  therefore,  one 
that  is  made  up  of  the  specific  bacteria  that  are  the  causal  agents  in  the 
condition  to  be  treated.  There  may  be  a  number  of  bacteria  of  differ- 
ent kinds  found  coexistent  in  a  given  lesion.  In  mixed  infections 
of  this  sort  it  will  be  necessary  to  determine  which  variety  is  the  disease 
producer.  In  case  the  responsibility  cannot  be  fixed,  it  will  be  neces- 
sary to  use  coincidentally  two  or  three  differently  constituted  vaccines  to 
properly  meet  a  mixed  infection.  If  investigation  shows  infection  to  be 
due  to  a  staphylococcus,  pneumococcus,  gonococcus,  or  to  the  tubercle 
bacillus,  it  is  commonly  satisfactory  to  make  use  of  corresponding 
stock  vaccine.  In  most  of  the  other  infections  the  infecting  organism 
should  be  derived  from  the  lesion  and  grown  in  pure  culture,  and  from 
this  culture  the  vaccine  prepared. 

LABORATORY  TECHNIQUE 

The  technique  to  be  followed  in  the  preparation  of  vaccine  varies  somewhat  accord- 
ing to  the  nature  of  the  organism  dealt  with.  The  preparation  of  a  staphylococcus  vaccine 
will  be  described  as  a  type,  and  modifications  necessary  in  dealing  with  other  species  will 
be  later  noted. 

The  water  of  condensation  in  three  or  four  tubes  of  nutrient  agar  is  inoculated  from 
a  pure  culture,  the  surfaces  thickly  inseminated,  and  incubated  for  a  period  of  from  twent}-- 
four  to  forty-eight  hours.  The  contents  of  a  test-tube  containing  lo  cc.  of  0.85  sterile  salt 
solution,  made  up  in  distilled  water,  is  poured  into  one  of  these  tubes,  and  the  growth 
rubbed  off  by  means  of  a  sterile  platinum  ^vire  (Fig.  217).  The  opalescent  emulsion  thus 
produced  is  poured  into  the  second,  then  into  the  third,  and  finally  into  the  sterile  tube 
which  originally  contained  the  salt  solution.  In  pouring  the  emulsion  from  one  tube  to 
another  great  care  must  be  taken  thoroughly  to  burn  off  and  heat  the  open  ends  of  the 
tubes.  They  must  be  held  slanted,  at  as  small  an  angle  as  possible  from  the  horizontal, 
at  all  times  while  being  manipulated,  in  order  to  prevent  air  contamination.     If,  during 


LABORATORY  TECHNIQUE  OF  VACCINE  PREPARATION 


66l 


the  course  of  the  preparation  an  open  tube  is  temporarily  set  aside,  it  should  be  slanted  in 
the  same  manner  and  for  the  same  purpose.  The  final  tube  containing  the  emulsion  is 
then  heated  in  the  blow-pipe  flame,  drawn  out  and  closed,  and  shaken  vigorously  for  from 


Fig.  2i6. — Pouring  Sterile  Salt  Solution  into  Agar  Culture. 


Fig.  217. — Washing  off  Growth. 


Fig.  218. — Sterile  Tube  Containing  Emulsion. 


five  to  ten  minutes,  in  order  to  produce  a  homogeneous  emulsion.  The  scaling  of  a  test-tube 
containing  fluid  requires  some  skill,  the  result  of  practice.  The  tube,  held  at  an  angle  of 
45  degrees  or  less,  in  the  left  hand,  the  open  end  is  cautiously  heated  in  the  yellow  flame 


662 


THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 


until  it  is  dry,  both  inside  and  out,  up  to  two  or  three  inches  from  its  open  end.  Air  is 
then  turned  on,  and  with  the  blue  flame  the  extreme  end  of  the  tube  is  melted  and  a  short 
piece  of  glass  tubing  is  made  to  adhere  to  it,  which  shall  serve  as  a  handle  when  the  tube 
is  drawn  out  (Fig.  219).    The  tube  is  then  rotated  continuously  in  the  flame,  which  impinges 


Fig.  219. — Tube  Containing  Bacterial  Emulsiox,  with  Handle  Attached    as  an  Aid  in  Sealing* 


Fig.  ;!2o. — Tube  Partially  Drawn  with  Walls  Thickened. 


Fig.  221. — Tube  Completely  Drawn  Out. 


as  near  the  end  as  possible.  When  the  wall  of  the  tube  is  molten,  the  glass  walls  of  the 
tube  are  allowed  to  run  together,  in  order  to  thicken  <^he  wall  of  the  portion  that  is  to  be 
drawn  out.     If  this  process  of  thickening  is  not  accomplished,  the  wall  of  the  portion  drawn 


STANDARDIZATION    OF    A   VACCINE 


663 


out  may  be  too  thin  to  be  serviceable  (Fig.  220).  When' properly  thickened,  the  tube  is 
drawn  out  while  still  in  the  flame  until  the  diameter  of  the  molten  part  is  two-thirds  that  of 
the  cool  portion.  It  is  then  removed  from  the  flame,  and  immediately  drawn  out  until 
the  tapered  portion  is  |  in.  or  so  in  diameter  and  3  or  4  in.  long  (Fig.  221).  The  tube  is 
then  allowed  to  cool,  heated  subsequently  in  a  small  flame,  sealed,  and  allowed  to  stand  up- 
right until  cool  (Fig.  222). 


Fig.  222. — Tube  Sealed,  Ready  for  Shaking. 


Standardization. — After  thorough  shaking  (fifteen  minutes  is  sufficient),  the  tapered 
end  is  deeply  scratched  with  a  file  or  glass-cutting  knife,  J  in.  from  the  end  (Fig.  223), 
broken  off,  sterilized  in  the  Bunsen  flame,  cooled,  a  few  drops  expressed  into  a  clean  watch- 
glass  or  other  receptacle  (Fig.  224),  and  the  open  end  of  the  tube  resealed.  It  will  com- 
monly be  found  that  the  shaking  has  not  broken  up  the  clumps  of  bacteria,  and  that,  there- 
fore, further  manipulation  is  necessary,  that  the  portion  of  the  emulsion  to  be  standardized 
may  contain  as  few  and  as  small  clumps  of  bacteria  as  possible.     For  this  purpose,  a  small 


Fig.  225.— Scratching  Tube  with  Glass  Cutting  Knife,  in  Order  to  Break. 

pipet  is  drawn  out  with  a  capillary  portion  about  i  mm.  in  diameter,  and  cut  off  squarely 
about  I  in.  from  the  stub.  A  rubber  teat  is  affixed  to  this  pipet,  the  emulsion  is  drawn  in 
and  out  forcibly,  the  pipet  being  held  at  right  angles  to  the  table  against  the  bottom  of 
the  watch-glass  (Fig.  225).  By  this  means,  further  breaking  up  is  effected.  The  emul- 
sion should  then  contain  bacteria  singly,  in  pairs,  or  in  very  small  groups. 

A  capillary   pipet,   drawn  from  ^-in.    glass   tubing,  exactly  the   same   as   the   pipet 
used  for  opsonic  index  determination,  the  capillary  end  being  about  5  in.  long,  cut  squarely, 


664 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


is  marked  with  a  glass  marking-pencil  f  in.  from  the  tip.     A  ligature  is  bound  round  the 
thumb  of  the  left  hand,  the  dorsum  is  pricked  near  the  nail  with  a  blunt  glass  needle  (Fig. 


Fig.  224. — Expressing  a  Few  Drops  of  Emulsion  for  Standardization;  Heat  of  Hand  Expands  the  Air 
IN  the  Tube,  and  Forces  Out  the  Fluid. 


Fig.  225. — Breaking  up  a  Bacterial  Emulsion  for  Standardization,  or  for  Opsonic  Index  Determina- 
tion BY  PiPETING. 


Fig.  226.—  Pricking  Thumb  with  Glass  Needle. 


226).     A  rubber  teat  having  been  fitted  to  the  pipet,  three  or  four  volumes  of  0.S5  salt 
solution  are  drawn  in,  then  one  volume  of  blood,  one  of  bacterial  emulsion,  and  again 


LABORATORY   TECHNIQUE 


665 


three  or  four  volumes  of  salt  solution  (Fig.  227).  The  volumes  of  blood  and  emulsion 
must  be  separated  from  each  other  and  from  the  salt  solution  in  the  pipet  by  air-bubbles; 
that  is,  as  each  volume  is  aspirated,  it  is  allowed  to  run  upward  in  the  pipet,  so  that  a 
space  is  left  before  the  next  volume  is  aspirated.  The  "volume"  referred  to  is  the  amount 
of  fluid  between  the  end  of  the  pipet  and  the  pencil-mark.  The  amount  of  salt  solution 
used  does  not  alter  the  final  results  and  need  not  be  accurately  measured.     The  contents 


Fig.  227. — Taking  up  One  Volume  of  Bi.god  into  Pipet  for  Standardization. 

of  the  capillary  are  then  thoroughly  mixed  on  a  glass  slide  by  alternately  pressing  and 
releasing  the  rubber  teat  (Fig.  228),  in  order  that  in  the  mixture  there  shall  be  an  even 
distribution  of  bacteria  and  red  corpuscles.  A  small  drop  is  then  expressed  on  each  of 
two  or  three  clean  glass  slides  (Fig.  229),  and  with  the  end  of  a  fresh  slide  a  smear  is 
made  (Fig.  230)  and  allowed  to  dry.  These  smeared  slides  are  then  immersed  in  a  satu- 
rated solution  of  mercuric  chlorid  for  three  minutes,  and  stained  with  carbolthionin  blue 


Fig..  228. — Mixing  Blood  and  Emulsion. 
Each  one  volume  and  several  volumes  of  normal  salt  solution  on  slide. 


for  about  one  minute  cold  (thionin  pure,  Griibler,  \  per  cent.,  carbolic  acid,  i  per  cent.). 
If  stained  properly,  the  red  corpuscles  will  have  a  light  green  and  the  bacteria  a  deep 
purple  tint. 

The  actual  standardization  consists  in  counting  the  number  of  red  corpuscles  and 
bacteria  contained  in  a  series  of  fields  of  equal  size  in  one  of  these  slides,  until  500  red 
corpuscles  and  the  number  of  bacteria  met  with  have  been  enumerated.  In  order  to  make 
counting  easier,  a  more  restricted  field  than  that  allowed  by  the  eye-piece  is  of  advantage, 
and  to  this  end  four  hairs  arc  made  to  adhere  to  the  diaj^hragm  inside  the  cye-picce,  in  such 


666 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


position  that  a  small  square  field  will  be  marked  off  and  projected  on  the  slide  for  a  counting 
area.  The  number  of  cells  and  bacteria  in  each  field  are  noted,  added,  and  when  500 
cells  have  been  counted,  the  follo-^-ing  proportion  is  worked  out.  Supposing  that  in  count- 
ing 500  cells  600  bacteria  have  been  encountered,  the  proportion  is  as  follows:  500  (red 
cells)  :  600  (bacteria)  as  5,000,000,000  (the  number  of  red  cells  in  i  cc.  of  normal  blood) 
is  to  jf.     X  —  6,000,000,000  of  bacteria  to  the  cubic  centimeter. 


Fig.  229. — A  Small  Drop  of  Mlxed  Blood  axd  EiiuLSiON  on  Each  of  Two  Slides,  Ready  for  SiiEARS. 

The  requirements  for  accuracy  in  this  method  of  standardization  are  that  the  indi- 
vidual whose  corpuscles  are  used  shall  have  an  approximately  normal  red  count;  that  the 
bacterial  emulsion  shall  be  free  from  clumps;  that  where  fields  containing  suggestions  of 
hemolyzed  red  cells  are  met  with,  they  should  be  excluded;  fields  should  be  counted  in 
■R-idelv  separated  portions  of  the  slide  to  insure  fair  average.  At  its  best,  this  numerical 
test  of  the  vaccine  is  but  an  approximation,  but  it  is  quite  accurate  enough  for  use.  Quite  as 
important  as  the  number  of  the  bacteria  is  their  virulence,  which  cannot  be  measured  except 


Fig.  230. — Making  Smear. 


by  the  method  of  trial  and  error  upon  the  patient.  To  avoid  error  we  use  minute  doses  of 
the  vaccine  to  start  in  the  case  of  any  vaccine  that  has  never  been  tried.  The  actual  numer- 
ical standardization  of  a  vaccine,  then,  by  these  methods,  has  been  satisfactorily  arrived  at. 
A  more  accurate  count  is  possible,  and  much  easier  accomplished,  if  on  the  slide  to 
be  counted  the  number  of  red  cells  about  equal  that  of  the  bacteria.  Hence,  if  before 
Tnixing  the  blood  and  emulsion  for  standardization  the  vaccine  appears  to  be  extremely 
thick,  sterile  salt  solution  should  be  added  in  sufficient  quantity  properly  to  dilute;  if  the 


STERILIZATION    OF    A    VACCINE 


667 


emulsion  appears  to  be  thin,  as  in  the  case  of  streptococcus  and  pneumococcus  vaccine, 
two  to  six  volurhes  of  emulsion  should  be  used  to  one  of  the  blood.  Experience  teaches 
one  to  judge  the  probable  content  of  a  bacterial  emulsion  per  cc.  from  its  opacity,  so  that 
the  proper  adjustment  can  be  made  from  inspection. 

Sterilization. — As  soon  as  the  few  drops  of  emulsion  are  expressed  from  the  tube  for 
standardization,  the  tube  is  sealed  and  at  once  immersed  in  a  water-bath  at  60°  C,  in  which 


Fig.  231. — Water-bath  for  Sterilizing  Vacci!*es. 
.4,  Metal  thermoregulator;   B,  wire  basket;   D,  Spindle  attached  to  bottom  of  basket;  C,  Diaphragm  with  set- 
screw,  for  holding  tubes  of  vaccine  beneath  the  surface  of  water.     This  slides  on  spindle  D. 

it  is  allowed  to  remain  for  one  hour.  The  shorter  the  exposure  to  heat,  the  less  the  vac- 
cinating quality  of  the  vaccine  should  suffer.  After  the  period  of  steriUzation,  care  ha\-ing 
been  taken  that  the  temperature  of  the  bath  has  remained  constant,  and  that  the  tube  has 
been  completely  immersed,  it  is  removed  from  the  bath,  the  end  broken  off,  and,  with 
sterile  precautions,  one  or  two  drops  of  emulsion  is  expressed  upon  the  surface  of  an  agar 


Fig.  232. — Expressing  Drop  op  Vaccine  on  Surface  of  Agar  Slant,  for  Test  of  Sterility. 


slant  (Figs.  232,  233).  This,  incubated  twelve  hours,  will  show  whether  or  not  the  vac- 
cine has  been  successfully  sterilized.  After  sterilization,  a  label  is  affixed  to  the  tube  con- 
tainer stating  the  kind  of  vaccine,  its  derivation,  number  of  bacteria  per  cubic  centimeter, 
the  length  of  time  sterilized,  and  the  date.  The  vaccine  should  not  be  used  for  inocula- 
tion until  the  test  culture  has  been  incubated  at  least  twelve  hours  and  is  proved  to  be 
sterile. 


668 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


Keeping  qualities  of  vaccine  may  be  insured  by  storing  the  stocks  in  a  cool  place. 
It  is  probable  that  there  is  some  deterioration  month  by  month.  A  toxin,  such  as  old 
tuberculin,  appears  not  to  retain  its  vaccinating  power  for  more  than  a  few  weeks  if  di- 
luted. Tuberculin  R,  and  the  so-called  bacillen  emulsion,  apparently  lose  none  of  their 
efficiency  in  the  various  dilutions,  even  after  several  months.     The  writer  has  used  a 


Fig.  233. — Expressing  Drop  of  Emulsion  on  Sterile  Platinltm  Loop,  for  Test  of  Sterilitv  of  Vaccine. 


staphylococcic  vaccine  which  he  prepared  in  Wright's  laboratory  for  over  a  year,  and  has 
noted  very  little  diminution  in  its  vaccinating  qualities,  even  though  it  has  been  kept  at 
room  temperature.  It  is  not  necessary  to  keep  vaccines  upon  ice  if  they  are  to  be  used 
within  two  or  three  months. 


Fig.  234. — Essentials  for  Blood  Cultures. 
A,  "Collin"  syringe,  sterilized  with  oil  at  140°  C,  inserted  into  a  sterile  8"  by  i"  test-tube;  the  needle  in 
cotton  plug;  a  heavy  rubber  test-tube  cap  holds  syringe  in  tube;  B,  bouillon  in  8"  by  i"  tube  sealed;  C,  bile  in 
8"  by  i"  tube  sealed;  D,  lysol;  E,  alcohol  lamp;  F,  glass-cutting  knife. 

If  one  desires  to  prepare  large  amounts  of  vaccine,  methods  used  by  commercial 
houses  may  be  employed.  In  dealing  v.'ith  a  large  inoculation  clinic,  the  writer  has  found 
that  the  preparation  of  considerable  quantities  at  one  time  is  desirable.  For  this  purpose 
mass  cultures,  grown  on  the  surface  of  agar  in  Roux  flasks,  or  large  flat  eight  or  sixteen- 
ounce  bottles  with  wide  necks,  furnish  the  necessary  growth.  To  inoculate  such  bottles  a 
twelve-hour  growth  of  the  organism  in  bouillon  is  poured  over  the  surface  of  the  receptacle 


SOTTLING    THE    VACCINE 


669 


and  stood  upright  in  the  incubator.  The  sterile  salt  solution  used  in  the  preparation  may 
amount  to  50  cc.  or  more,  and  it  is,  therefore,  convenient  to  use  as  containers  8  by  i  inch 
extra  heavy  test-tubes,  which  will  be  the  final  containers  for  the  stock  vaccine.  Care  must 
be  used  in  burning  off  the  neck  of  a  bottle  or  flask,  both  inside  and  out,  before  making  any 
transfers  of  fluid  by  pouring.  There  is  less  danger  of  air  contamination  if  the  transfer 
of  emulsions  is  made  by  means  of  pipets.  The  method  of  sealing  the  large  tubes  is  sim- 
ilar to  that  where  a  smaller  one  is  used.     The  other  steps  in  the  preparation  of  stock  are 


Fig.  235. — Ready  for  Adding  Lysol  to  Bottle  of  Sterile  8s  Per  Cent.  Salt  Solution.    Cotton 

Plug  Removed. 

as  stated.     It  is  well  to  have  the  bacterial  contents  of  stocks,  in  case  of  staphylococcus, 
from  5,000,000,000  to  15,000,000,000  per  cc. 

Bottling  the  Vaccine. — The  next  step  is  to  dilute  a  portion  of  the  vaccine  prepared, 
in  such  strength  and  in  such  containers  as  will  make  it  convenient  for  actual  use  in  the 
treatment  of  patients.  In  the  case  of  our  staphylococcus  vaccines,  three  strengths  are 
desirable:  one  bottle  containing  200,000,000  organisms  per  cc,  another  500,000,000,  and 


Fig.  236.— Adding  Lysol,  i  of  iPer  Cent.,  to  Vaccine  Bottle  Containing  Sterilf.  85  PeR  Cent.  Salt 
Solution.     Cotton  Plug  is  Then  Replaced. 

a  third  1,000,000,000.  A  convenient-sized  bottle  for  staphylococcic  vaccine  contains  50  cc, 
but  where  a  small  number  of  cases  are  being  treated,  bottles  of  15  cc.  capacity  are  more 
satisfactory. ' 

The  mode  of  preparation  of  these  vaccine  bottles  is  as  follows:  A  number  of  large- 
mouthed  ^-ounce  "French  square"  bottles  arc  washed  with  weak  hydrochloric  acid  solu- 
tion, rinsed  with  water,  and  dried  out  thoroughly  by  inverting  over  a  heater.  The}-  are 
then  plugged  lightly  with  cotton  and  placed  in  a  dry  sterilizer  for  one  hour,  in  order  to  set 


670 


THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 


the  cotton  plugs.  With  a  large  pipet  there  is  added  to  each  bottle  15  cc.  of  0.S5  per  cent. 
salt  solution,  made  up  with  distilled  water,  and  the  cotton  plugs  replaced.  These  bottles 
are  then  autoclaved  for  one-half  hour  at  fifteen  pounds  pressure.  To  each  bottle  is 
then  added  35  cmm.  of  pure  13'sol,  and  the  cotton  plug  replaced  (Fig.  236).  The  method 
of  adding  this  lysol  is  as  follows:  By  means  of  a  standard  millimeter  pipet,  35  cmm.  of 


Fig.  237. — After  Sterile  Rubber  Cap  is  Aseptically  Applied  to  "  Blank"  Vaccine  Bottle,  the  Latter 
IS  Dipped  into  Melted  Paraffej  (at  140°  C;  to  Seal. 

mercury  are  measured  out  and  drawn  into  a  pipet  similar  to  that  used  for  standardization 
purposes.  This  pipet  is  marked  off,  so  that  the  above  quantity  of  lysol  can  be  measured. 
The  pipet  is  then  sterilized  in  the  flame  and  used  for  the  above  purpose.  Each  bottle 
will  then  contain  85  per  cent,  sterile  salt  solution,  with  |-  of  i  per  cent,  (approximately)  of 
lysol  as  a  preservative. 


Fig.  238. — Applying  Cap  to  Vaccine  Bottle. 


These  bottles  are  then  to  be  covered  with  sterile  rubber  caps,  such  as  those  used  in 
Wright's  laboratory.  The  rubber  should  be  thick  and  of  pure  gum,  and  of  such  con- 
sistency that  it  will  heal  after  each  puncture  of  the  hypodermic  needle. 

This  cap  should  be  rinsed  in  water  and  boiled  ten  to  fifteen  minutes  in  a  10  per  cent, 
lysol  solution.  The  bottles  should  be  taken  one  at  a  time,  held  at  an  angle  of  45  degrees 
or  less,  the  neck  burned  off  in  a  Bunsen  flame,  with  sterile  forceps  the  cap  removed  from 
the  lysol  solution,  and  stretched  over  the  neck  of  the  bottle  aseptically.     As  each  bottle 


BOTTLING    THE    VACCINE 


671 


is  capped,  with  the  thumb  pressed  tightly  against  its  top  (Fig.  238),  it  is  a^once  shaken  in 
order  thoroughly  to  distribute  the  lysol,  otherwise  it  is  apt  to  be  stringy  and  break  up  into 
small  flocculi  later.  After  all  the  bottles  are  thus  capped  and  shaken  they  are  inverted, 
and  the  cap  dipped  into  melted  paraffin  in  order  thoroughly  to  seal  (Fig.  237).  These 
bottles  m.ay  be  termed  "blanks,"  and  are  to  be  used  as  containers  for  vaccine  for  use  on 
the  individual  patient. 

The  m.ethod  of  transferring  the  vaccine  from  the  stock  tube  which  we  have  just  pre- 
pared is  as  follows:  if  we  desire  the  vaccine  to  contain  1,000,000,000  per  cc,  we  find  that 


Fig.  239. — Abstracting  Standardized  and  Sterilized  Vaccine  from  Stock  Tube. 

we  need  in  our  15  cc.  bottle  atotalof  15,000,000,000  organisms.  There  being  6,000,000,000 
organisms  (in  this  case)  in  each  cc.  of  our  stock,  simple  calculation  will  show  that  it  is 
necessary  to  add  2^  cc.  of  the  stock  to  the  solution  in  the  bottle.  Before  adding  the  vac- 
cine, however,  we  must  abstract  an  equal  amount  of  fluid  from  the  bottle.  These  transfers 
are  made,  using  a  2  cc.  syringe  graduated  to  ro  cc.  A  drop  of  pure  lysol  is  placed  upon 
the  rubber  cap  of  the  "blank"  bottle,  the  sterile  needle  is  inserted  through  this  lysol,  the 


Fig.  240.- 


-Injectixg  Proper  Amoitnt  of  Vaccine  into  Bottle  of  Sterilf,  Lvsolizf.d  Salt  Solution,  for 
Actual  Use,  in  Treatment. 


bottle  inverted,  and  the  amount  withdrawn.  The  tube  containing  the  stock  vaccine  is 
vigorously  shaken  for  a  minute  or  two,  the  end  of  the  tapered  portion  is  broken  off,  flamed, 
and  the  tube  field  in  the  left  hand  inverted.  If  the  fluid  does  not  enter  the  tapered  portion 
far  enough  for  the  needle  to  reach  it,  the  heat  of  the  hand,  plus  a  Httlc  shaking,  will  often 
suffice  to  effect  this.  If  not,  the  but  end  of  the  tube  may  be  held  near  a  Bunsen  flame. 
The  proper  amount  of  emulsion,  in  this  case  2*  cc,  is  to  be  withdrawn  and  injected  through 
the  rubber  cap  inlcj  the  bottle  (Fig.  240).     The  bolllc  will  now  contain  15  cc,  each  cubic 


67:2 


THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 


centimeter  which  will  hold  1,000,000,000  of  organisms.  This  bottle,  after  being  labeled 
properly  and  shaken,  is  ready  for  use. 

If  the  vaccine  stock  be  a  large  one,  or  apt  to  be  opened  frequently,  it  is  best  to  add, 
as  a  preservative  before  closing,  J  per  cent,  lysol.  If  the  amount  of  emulsion  to  be  added 
to  each  bottle  is  more  than  10  per  cent,  of  its  total  bulk,  the  stock  should  always  previously 
receive  i  per  cent,  lysol,  in  order  that  the  completed  vaccine  may  still  have  the  full  J  per 
cent,  of  lysol.  To  estimate  roughly  the  amount  of  vaccine  in  a  tube,  in  order  to  determine 
the  proper  amount  of  lysol  to  add,  the  tube  is  immersed,  up  to  the  level  of  the  vaccine,  in 
a  graduated  beaker  with  some  water  in  it  and  the  rise  in  the  water  noted.  Allowance  of 
the  thickness  of  the  vaccine  container  must  be  made  and  subtracted. 

Carbolic  acid,  I  per  cent,  to  ^  per  cent,  or  more,  may  be  used  as  a  preservative  instead 
of  lysol.     The  advantage  of  the  former  is  that  the  vaccine  is  less  opalescent  and  does  not 


Fig.  241. — Simple  Apparatus  for  Oil  Steriliza- 
tion, Consisting  of  Ring  Stand. 
A,  Thermometer;   B,  porcelain  dish  for  oil;   C, 
burner  (Bimsen);  D,  clamp  for  thermometer;  E,  ring 
for  dish. 


Fig.  242.  —  Oil  Bath  for  Sterilization  of 
Syringes  Used  in  Inoculation,  Prepara- 
tion OF  Vaccines,  and  Taking  Blood  Cul- 
tures, Etc. 

A,  Thermometer;  B,  bimetallic  thermo-regula- 
tor;  C,  gas  inlet  and  pipe  leading  through  regulator; 
D,  2-foot  "Bray"  burner;  E,  prolongation  of  ojl  re- 
ceptacle to  accommodate  thermometer  and  regula- 
tor. 


develop  a  flocculent  precipitate,  which  occasionally  forms  when  lysol  is  used.  It  appears 
to  the  writer  that  lysolized  vaccines  are  more  efficient  than  those  preserved  by  carbolic  acid. 
Method  of  Sterilizing  Syringes. — The  syringe  is  so  continuously  in  use  in  making 
vaccines  and  in  inoculating  patients,  that  some  more  ready  and  effectual  method  for  in- 
stantaneous sterilization  than  boiling  affords  is  of  great  advantage.  Sterilization  by  boil- 
ing is  slow,  inefficient,  and  causes  the  syringe  to  deteriorate.  The  method  introduced  by 
Wright  for  sterilizing  syringes,  by  filling  and  refilling  several  times  with  cotton-seed  oil, 
kept  at  a  temperature  of  130°  to  150°  C,  meets  every  requirement.  These  temperatures 
at  once  kill  bacteria  or  spores;  that  is,  they  give  us  an  instantaneous  autoclaving  effect. 
Besides,  the  oil  keeps  the  syringe  always  in  easy  working  order.     Syringes  of  the  Roux- 


THE    TUBERCULINS  673 

Collin  or  the  Ermold  tvpe  will  stand  these  temperatures  with  rare  breakage.  The  writer 
has  used  a  single  Ermcld  syringe  for  four  months  without  replacement  of  any  part  save 
the  needle.  A  simple  and  satisfactory  oil  bath  is  here  illustrated  (Fig.  241).  A  more 
satisfactory  oil  bath,  however,  is  one  ha^•ing  a  device  for  regulating  the  temperature  con- 
stantly at  the  desired  point  (Fig.  242). 

The  preparation  of  a  streptococcus  vaccine  requires  the  cultures  to  be  grown  for  from 
one  to  three  days,  and  that  once  or  twice  during  this  time  a  sterile  platinum  wire  be  carried 
over  the  surface  in  order  to  cause  thick  insemination.  One  or  two  bouillon  cultures  planted 
at  the  same  time  should  be  used  to  wash  off  the  agar  growth  instead  of  salt  solution,  in  order 
to  fortify  the  emulsion.  The  breaking  up  of  the  chains  of  streptococcus  for  standardiza- 
tion purposes  is  difficult,  and  a  more  prolonged  shaking  and  pipeting  than  in  the  case 
of  staphylococcus  and  some  other  bacteria  v/ill  always  be  required.  A  streptococcus 
emulsion  may  contain  from  200,000,000  to  1,000,000,000  per  cubic  centimeter,  and,  con- 
sequently, in  standardizing  one  must  take  from  three  to  six  times  as  much  emulsion  as 
blood,  according  to  one's  estimate  as  to  the  probable  content  of  the  emulsion  from  gross 
appearances.  Streptococcus  vaccines  should  be  bottled  for  actual  use  in  strengths  of  from 
50,000,000  to  200,000,000  of  bacteria  per  cc. 

Pneumococcus  and  gonococcus  vaccines  differ  from  the  staphylococcic  vaccine  in  the 
mode  of  preparation  only  in  their  difficulty  in  growth,  and  in  their  requirement  that  special 
culture-media  should  be  used;  i  cc.  of  hydrocele  fluid  or  human  serum  for  each  tube. 
For  the  pneumococcus  sheep  serum  may  be  used.  For  this  purpose  50  cc.  of  clear  sheep 
serum  is  added  to  100  cc.  of  distilled  water,  and  sterilized  for  fifteen  minutes  at  10  pounds 
pressure  in  an  autoclave.  The  resulting  fluid  will  be  quite  opalescent,  but  they  will  con- 
tain no  flocculi.  One  or  2  cc.  of  this  added  to  each  tube  of  nutrient  agar  makes  a  fair 
medium.  Emulsification  of  pneumococcus  is  somewhat  more  difficult  than  of  staphylo- 
coccus.    Fifteen  minutes'  shaking,  plus  five  minutes'  pipeting,  will  be  necessary. 

Colon  and  typhoid  vaccines  may  be  sterilized  in  forty-five  minutes,  and  at  a  temperature 
of  58  °  C,  or  for  seventy  minutes  at  53  °  C.  Emulsification  is  very  easy  and  very  little  pipet- 
ing is  required.  In  standardization  of  typhoid  vaccine  a  blood  should  be  used  which  does 
not  agglutinate  typhoid  bacilli.  For  curative  inoculation,  t3'phoid  vaccine  should  be  bottled 
in  strengths  of  100,000,000  to  200,000,000  per  cc. 

THE  TUBERCULINS 

Tuberculin  R  and  tuberculin  O  are  the  results  of  a  process  of 
grinding  the  bodies  of  virulent  tubercle  bacilli  into  a  fine  powder.  The 
bacilli  are  finely  comminuted,  suspended  in  water,  and  centrifugalized. 
The  deposit  is  called  tuberculin  R,  the  supernatant  cloudy  fluid  tuber- 
culin Q.  The  former  is,  then,  bacillary  substance  with  some  soluble 
portions  of  the  bacilli  removed;  the  latter  is  an  opalescent  solution  of 
the  substances  soluble  in  water. 

Bacillary  emulsion,  or  B.  E.,  is  a  suspension  of  the  comminuted  bodies 
of  tubercle  bacilli.  It,  therefore,  contains  all  the  immunizing  substances 
of  the  bacilli,  whereas  tuberculin  R  is  minus  certain  soluble  constitu- 
ents. Although  there  are.  many  other  tuberculin  preparations,  the  three 
mentioned  are  the  most  commonly  used  in  the  treatment  of  the  types  of 
tuberculosis  with  which  this  article  deals. 

The  preparation  of  these  tuberculins  for  actual  use  on  the  patient  consists  in  making 
proper  dilutions  of  the  concentrated  preparations  obtained  from  manufacturers.     Tuber- 
43 


674  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

culin  R  is  commonly  sold  in  vials  containing  i  cc.  of  fluid  in  which  there  are  2  mg.  of 
vaccinating  substance  (Miester,  Lucius,  and  Bruning).  Bacillary  emulsion  may  be 
obtained  in  5  cc.  vials,  each  cubic  centimeter  containing  5  mg.  of  bacillary  substance. 

It  is  convenient  to  prepare  for  actual  use  three  strengths  of  tuberculin  R  and  of  bacillary 
emulsion,  one  to  contain  ^^^  mg.  per  cc,  another  i^jjet  mg.  per  cc,  and  a  third  ^uVu  mg.  per 
cc,  in  order  that  the  dosage  may  be  accurately  administered.  Before  making  dilutions  of 
the  German  product  it  has  been  found  best  to  steriUze  the  original  preparation  for  one 
hour  at  60°  C.  If  sterilization  is  to  be  done,  it  will  be  necessary  to  make  two  of  Wright's 
so-called  "  curly  pipets."  For  this  purpose  apiece  of  tf  or  |-inch  tubing,  6  in.  long,  is 
heated  in  its  middle  and  drawn  out  into  a  |-inch  capillary,  and  cut  off  so  that  the  tapered 
end  of  each  tube  will  be  4  or  5  in.  long.  The  undrawn  end  is  then  heated  at  a  point  such 
that  will  allow  at  least  i  cc.  of  fluid  to  be  drawn  into  the  tube.  After  the  glass  is  thor- 
oughly molten  at  this  point,  it  is  drawn  out  so  that  there  will  be  a  constricted  portion  a 
little  over  an  inch  long,  and  while  still  pliable,  the  end  of  the  tube  is  rotated  in  its  long  diam- 
eter or  twisted  so  that  the  drawn-out  portion  is  given  a  complete  recurve  (Fig.  243).  This 
tube  is  sterilized  in  the  flame.  A  second  is  prepared  in  the  same  way,  and  likewise  steril- 
ized. The  vial  containing  tuberculin  is  unstoppered,  the  mouth  flamed,  and  the  contents 
drawn  up  into  the  curly  pipet  and  the  end  sealed;  i  cc.  of  sterile  salt  solution  is  poured 
into  the  vial  to  completely  wash  out  the  tuberculin  which  may  have  been  adherent  to  the 
interior  of  the  vial.  This  is  drawn  up  into  the  second  pipet,  which  is  likewise  sealed. 
These  two  pipets  are  then  suspended  for  one  hour  in  a  water-bath  at  60°  C.  We  then 
have  2  cc.  of  tubercuUn  R,  in  which  there  is  a  total  of  2  mg.  of  solid  substance.     To  an 


Fig.  243. — Wright's  "Curly  Pifet"  Used  as  a  Container  for  Tuberculin  During  Sterilization. 

8  by  I  test-tube,  containing  exactly  48  cc.  of  sterile  85  per  cent,  salt  solution,  the  contents  of 
these  two  pipets  are  added,  and  the  tube  drawn  out  in  the  flame  and  sealed  as  previously 
described.  We  then  have  a  solution  of  tuberculin  R  which  contains  nV  mg.  per  cc.  .  The 
bacillary  emulsion  should  be  sterilized  and  prepared  in  the  same  manner.  In  this  case, 
however,  but  i  cc.  of  the  fluid  is  withdrawn  from  the  original  vial  under  sterile  precautions, 
the  stopper  replaced,  and  the  remainder  saved  for  future  use.  Certain  American  prepara- 
tions of  tuberculin  do  not  require  sterilization,  according  to  the  statement  of  the  manu- 
facturers. The  technique  of  diluting  these  preparations  may  be  as  follows:  To  an  8  by  i 
tube,  containing  48  cc.  of  sterile  salt  solution,  i  cc.  of  tuberculin  R  is  added,  using  a  sterile 
syringe.  The  vial  is  then  washed  out  with  i  cc.  of  sterile  salt  solution  and  this  added.  We 
then  have  a  solution  containing  -jV  mg.  per  cc.  The  tube  is  sealed  and  labeled.  The 
dilutions  made  in  this  manner  are  kept  as  stocks,  and  from  them  further  dilutions  arc  made 
for  actual  use — 125  cmm.  of  lysol  should  be  added  to  each  50  cc.  stock  solution.  To 
prepare  a  solution  to  contain  y^^  mg.  per  cc,  we  find  that,  using  a  15  cc.  bottle  of  lysolized 
salt  solution,  we  require  a  total  of  j-gfj  mg.  of  bacillary  substance.  There  being  ^  mg.  in 
every  cubic  centimeter  of  the  stock,  we  find  that  we  require  0.37  cc.  of  the  stock.  This 
amount  having  been  extracted  from  a  blank  lysol  salt  vaccine  bottle  with  a  sterile  syringe, 
the  same  amount  of  the  stock  is  injected  through  the  rubber  cap  and  the  bottle  well  shaken. 
To  prepare  a  bottle  to  contain  -gi-^  mg.  per  cc.  twice  this  amount  of  the  stock  must  be  added. 
To  prepare  a  bottle  to  contain  -ji^tj  mg.  per  cc.  we  must  transfer  3  cc.  from  the  bottle  con- 
taining j(}(jjj  mg.  per  cc.  Before  these  additions  are  made,  equal  quanta  of  the  contents 
of  the  blank  vaccine  bottles  must  be  abstracted. 

Tuberculin  O  is  used  fcr  the  von  Pirquet  tuberculocutaneous  test.      It  is  convenient 


THE    DETERMINATION    OF    THE    OPSONIC    INDEX 


675 


for  use  to  have  old  tuberculin  in  sealed  capillary  tubes,  each  one  containing  sufficient  un- 
diluted tuberculin  for  a  single  test.  Three-eighth  inch  glass  tubing  is  di-awn  out  into  a 
fine  capillary,  the  long  tube  thus  made  is  cut  into  2-inch  lengths,  one  end  of  each  sterilized, 
and  inserted  into  the  tuberculin  container.  The  fluid  readily  runs  into  these  tubes  by 
capillary  traction.     Both  ends  are  then  sealed  in  the  flame. 


THE  DETERMINATION  OF  THE  OPSONIC  INDEX 

Opsonic  index  estimation  requires  the  preparation  of — (i)  a  corpuscular  mixture;  (2) 
a  bacterial  emulsion;  (3)  the  serum  of  several  persons  not  infected  by  the  organisms  with 
which  we  are  dealing,  and  (4)  the  serum  of  the  patient  or  patients  to  be  tested.  The  blood 
specimens  are  collected  in  small  recurved  capsules. 

(i)  Corpuscular  Mixture. — A  piece  of  glass  tubing  4  in.  in  length,  about  fs  in.  in 
diameter,  of  fairly  thick  walls,  is  heated  at  the  middle  in  a  small  blow-pipe  flame,  drawn 
out  quickly,  so  that  two  portions  of  equal  length  are  secured,  and  the  closed  end  of  each 
heated  and  rounded  (Fig.  244).  These  tubes,  which  are  ap- 
proximately the  same  length,  are  to  be  washed  thoroughly 
and  rinsed  with  sodium  citrate  solution.  They  are  then  to 
be  filled  two-thirds  full  of  sodium  citrate  solution,  i^  per  cent. 

A  blunt  glass  needle  is  made  by  heating,  in  the  pilot 
flame  of  a  Bunsen  burner  and  drawing  out  quickly,  an  odd 
piece  of  capillary  tubing.  After  winding  the  ligature  round 
the  base  of  the  thumb,  the  dorsum  is  pricked  near  the  margin 
of  the  nail.  The  blood  is  allowed  to  flow  as  quickly  as  pos- 
sible into  each  of  these  tubes  of  citrate  solution,  so  that  each 
will  contain  three  or  four  parts  of  citrate  solution  and  one  of 
blood.  As  the  blood  flows  in,  the  tube  is  occasionally  in- 
verted, the  open  end  being  closed  by  one  finger,  in  order  that 
there  shall  be  no  clotting  or  drying  of  blood  on  the  inner  sur- 
face of  the  tube.  These  tubes  are  then  inverted  several  times 
in  order  to  mix  thoroughly  the  blood  and  the  citrate  solution, 
care  being  taken  not  to  shake.  The  tubes  are  then  centrif- 
ugalized  long  enough  to  settle  all  the  corpuscular  elements. 
The  supernatant  fluid  is  pipeted  off,  and  the  tubes  are  filled 
with  sodium  chlorid  solution,  0.85  per  cent.,  and  again  inverted 
so  that  the  corpuscular  elements  are  thoroughly  mixed  and 
washed  free  from  serum,  then  centrifugalized  attain,  and  the 
supernatant  fluid  again  pipeted  off. 

We  now  have  a  mixture  of  red  and  white  corpuscles  in  a 
small  amount  of  salt  solution,  washed  free  from  the  blood- 
serum.  The  tubes  are  then  rotated  between  the  palms  of  the 
hand,  in  order  thoroughly  to  distribute  the  white  cells  in  all 
parts  of  the  mixture  (Fig.  245).  The  corpuscular  mixture  is 
now  ready  for  use,  and  the  tubes  are  placed  at  an  angle  of 
45  degrees  in  a  small  flat  dish  containing  wet  sand  as  a  holder, 
active  in  this  mixture  for  several  days,  but  in  opsonic  work  the  age  limit  for  use  should  be 
placed  at  twelve  hours  or  less. 

(2)  Bacterial  Emulsion. — This  is  made  from  living  cultures  of  the  organism,  against 
which  the  sera  are  to  be  tested.  The  period  of  growth  for  gram-positive  cocci  may  be  as 
long  as  twenty-four  hours;  for  gram-negative  cocci  and  organisms  of  the  colon  group  no 
longer  than  twelve  hours.  In  general,  the  younger  the  culture,  the  less  subject  it  is  to  the 
formation  of  clumps.  In  dealing  with  the  tubercle  bacillus  it  is  wiser  to  use  killed  organ- 
isms, and  apparently  c|uite  as  satisfactory  in  results.     A  small  amount  of  the  surface  growth 


Fig.  244. — Tubes  for  Blood- 
corpuscles,  i.  e.,  tOK 
"Corpuscular"  Mix- 
ture IN  Opsonic  Tech- 
nique. 
.1 ,  First  stage,  tubes  drawn 

out;    B,  end  of   tubes  sealed 

and  rounded. 


Lcukccvtcs  mav  rerhain 


676 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


of  agar  is  removed  on  a  sterile  platinum  loop,  and  is  mixed  with  a  few  drops  of  sodium 
chlorid  solution  in  a  watch-glass.  The  tubercle  bacillus  and  gram-negative  cocci  require 
a  15  per  cent,  salt  solution;  for  others  a  0.85  per  cent,  salt  solution  is  used.  The  purpose 
now  is  thoroughly  to  break  up  all  clumps  in  this  emulsion,  in  order  that  we  may  have 
chiefly  single  bacteria,  or,  at  the  worst,  groups  of  but  two  or  three.     In  order  to  bring  this 


Fig.  245. — Opsonic  Index  Technique. 
Rolling  tube  containing  corpuscular  mixture  thoroughly  to  mix. 


about,  a  good  method  is  to  draw  out  a  small  capillary  pipet,  cut  off  the  end  squarely 
about  I  in.  from  the  stub,, and  with  a  rubber  teat  forcibly  draw  in  and  express  the  emulsion, 
holding  the  end  of  the  tube  at  right  angles  to  the  bottom  of  the  watch-glass  (Fig.  245). 
The  length  of  time  required  for  this  procedure  depends  entirely  upon  the  nature  of  the 
organism  with  which  we  are  dealing.     In  the  case  cf  staphylococcus,  colon  bacillus,  or 


Fig.  246. — Glass  Recurved  Capsule  for  Blood 
Specimen  (Wright),  with  Fine  Needle  End 
FOR  Pricking  Finger. 


Fig.  247. — Glass    Recurved    Capsule  (Wright) 

FOR  Securing  Blood  Specimen. 
Heating,  in  order  to  make  needle  for  pricking  fmger 


gonococcus,  five  minutes  may  be  sufficient;  with  tubercle  bacillus,  streptococcus,  and  pncu- 
mococcus,  a  much  longer  time  is  necessary.  It  is  well  to  have  the  emulsion  at  first  a  great 
deal  thicker  than  is  necessary  for  the  actual  opsonic  test,  so  that  after  this  last  procedure 
we  can  centrifugalize  the  emulsion  in  order  to  remove  any  remaining  clumps.  After  cen- 
trifugalizing  the  upper  portion  of  the  fluid  is  pipeted  off,  and  to  this  salt  solution  of  ap- 


THE    OPSONIC    INCUBATOR  677 

propriate  strength  is  added,  if  necessary,  to  render  the  emulsion  of  proper  strength  for  use. 
Determination  of  the  proper  opacity  of  the  emulsion,  so  that  it  shall  give  us  a  convenient 
number  of  organisms  in  each  white  cell,  is  a  matter  of  judgment  based  on  experience. 
Ordinarily  an  emulsion  of  cocci  will  appear  less  opalescent  than  an  emulsion  of  bacilli  of 
the  same  strength.  The  preparation  of  the  tubercle  emulsion  is  more  difhcult  perhaps 
than  any  other.  One  should  obtain  some  dry  tubercle  bacilli  from  any  of  the  manufac- 
turers of  tuberculin  products,  or  it  is  quite  as  well  to  use  those  from  a  young  culture  steril- 
ized. If  the  dry  bacilli  are  used,  an  amount  which  can  be  taken  up  on  the  end  of  a  knife- 
blade  is  placed  in  a  small  agate  mortar,  and  with  a  pestle  ground  dry  until  it  has  an  even, 
smooth,  powdery  consistency;  1.5  per  cent,  salt  solution  is  then  added  drop  by  drop,  and 
the  rubbing  is  continued  until  a  paste  is  produced.  The  intent  is,  so  far  as  possible, 
to  separate  the  clumps  of  bacilli.  Then  more  salt  solution  is  added  gradually  and  the  re- 
sult, a  fairly  thick  emulsion,  is  pipeted  into  a  small  test-tube,  in  which  there  may  well  be 
a  number  of  small  glass  beads,  more  salt  solution  added,  the  tube  is  sealed  up,  thoroughly 


Fig.  248. — Opsonic  Incubator. 

shaken,  and  sterilized  for  one-half  hour  at  60°  C.  The  tube  is  then  inverted  and  stood 
upright  in  a  rack  for  a  day  cr  two,  until  the  drawn-out  end  of  the  tube  becomes  filled  with 
the  larger  clumps  of  the  bacteria,  the  upper  portion  cf  the  fluid  having  an  opalescent 
appearance.  The  drawn-cut  portion  is  then  cut  off,  and  the  tube  resealed  and  allowed  to 
stand  upright  for  two  or  three  days.  The  upper  opalescent  layers  are  now  to  be  used  as 
the  emulsion,  but  may  require  dilution,  further  breaking  up  by  pipeting,  or  further  cen- 
trifugalizing,  in  order  to  render  it  fit  for  use  as  an  emulsion.  Such  as  emulsion  once  pre- 
pared can  be  used  indefinitely  so  long  as  it  is  kept  sterile. 

(3)  Serum. — The  serum  should  be  collected  from  the  patient  in  the  small  curved 
capsules  made  of  y^Tj-in.  glass  tubing.  The  dorsum  of  the  thumb  ha\'ing  been  sterilized 
in  alcohol  and  the  ligature  applied,  the  blood  is  drawn,  as  previously  explained,  and  al- 
lowed to  flow  into  this  glass  capsule.  The  latter  is  then  sealed  in  the  flame,  particular 
care  being  taken  not  to  heat  the  blood,  inasmuch  as  the  opsonin  is  destroyed  if  heated  to 
60°  C.  or  over.  Serum  should  not  be  used  until  the  clot  has  formed  unless  the  red  cells 
are  centrifugalized.  Serum  from  normal  individuals  is  obtained  in  the  same  way,  and  is 
to  be  used  %s  a  control.  In  the'  determination  of  the  tUbcrculo-opsonic  index,  sera  from 
three  or  four  normal  individuals  are  separately  tested  for  contrc;l,  and  in  the  case  of  ether 
organisms,  equal  volumes  of  three  or  four  normal  sera  are  pooled,  and  the  resulting  serum 
tested  as  a  normal,  or  control. 

Technique. — We  have  then  the  essentials  for  determining  the  opsonic  index,  namely, 
corpuscular  mixture,   bai  lerial  emulsi<  n,   nc  rmal   sera,  and  the  patient's  serum,  to  be 


678 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


tested.  The  method  of  procedure  is  as  follows:  A  rubber  teat  is  fitted  over  the  large  end 
of  a  capillar)^  pipet,  and  a  mark  placed  upon  it  f  in.  from  the  capillary  end.  One  vol- 
ume of  corpuscles  is  drawn  up  a  little  beyond  the  end  of  the  tube,  lea^dng  an  air-space, 
followed  by  an  equal  volume  of  the  bacterial  emulsion,  then  an  air-space,  and  then  an 
equal  volume  of  serum  to  be  tested  (Fig.  249).     Thus  we  have  equal  volumes  of  each, 


Fig.  24g. — QpsoNic  Index  Technique. 
Pipeting  an  opsonic  mixture  prior  to  incubation. 

separated  by  air-spaces.  These  are  expressed  upon  a  clean  glass  slide,  and  alternately 
drawn  in  and  out  in  order  thoroughly  to  mix.  Pipeting  is  a  very  difficult  procedure  at 
first  and  it  requires  special  practice.  The  most  important  consideration  is  to  have  the  end 
of  the  pipet  cut  off   squarely.     If  this  is  done,  and  the  pipet  held  at  the  proper  angle 


Fig.  250. — Opsonic  Index  Technique. 
One  volume  of  corpuscles  and  one  volume  of   emulsion  have  already  been  taken  into  pipet. 

serum  is  being  drawn  in. 


One  volume  of 


of  45  degrees  or  slightly  less,  this  procedure  can  be  carried  out  without  bubbling.  The 
fluid  is  carefully  drawn  into  the  pipet,  excluding  air-bubbles,  the  end  is  sealed  in  the  flame, 
and  the  pipet  immediately  put  into  the  opsonic  incubator  (Fig.  248)  at  37°  C,  and  allowed 
to  remain  for  fifteen  minutes.  This  process  is  repeated  with  each  of  the  sera  to  be  tested. 
The  time  is  noted  when  each  pipet  is  placed  in  the  incubator.     In  the  case  of  the  colon 


THE    DETERMINATION    OF    THE    OPSONIC    INDEX 


679 


group  and  Gram-negative  cocci,  the  incubation  time  should  be  eight  or  nine  minutes; 
the  others  require  fifteen  minutes.  At  the  appropriate  time  the  pipets  are  withdrawn 
one  by  one,  the  contents  of  each  blown  out  upon  a  clean  sUde,  and  sucked  up  and  reex- 
pressed  until  the  mixture  is  thorough.  Then  a  small  drop  is  blown  on  each  of  two  slides 
and  a  suitable  smear  made.  On  the  efficient  manner  in  which  this  smear  is  made  depends, 
to  a  large  degree,  the  excellence-  of  the  preparation  and  the  ease  with  which  counting  may 
be  accomplished.  It  is  possible,  by  using  a  properly  made  slide  as  a  smearer,  to  produce 
a  film  in  which  practically  all  the  leukocytes  will  be  located  at  the  end  of  the  smear,  so 
that  in  counting  all  that  one  has  to  do  is  to  follow  a  rather  thickly  distributed  line  of  leuko- 
cytes across  the  slide.  Such  a  smear  is  time  sa\ang  and  conser\dng  of 
patience,  and  hence  lends  to  the  accuracy  of  the  results.  The  proper 
smearer  is  made  by  nicking  a  thin  glass  slide  at  its  center,  and  break- 
ing it  in  such  a  way  that  the  resulting  edge  will  be  slightly  concaved 
and  smooth.  The  corners  should  be  cut  off,  so  that  we  have  a  slightly 
concave,  sharp,  even  edge,  about  J  in.  long  (Fig.  252).  If  this  slide  is 
held  at  the  proper  angle,  which  varies  according  to  the  concavity  of 
the  edge,  and  may  be  determined  by  experience,  such  a  smear  is  pro- 
duced as  has  been  described  (Fig.  253). 


T0m 


Fig.    251. — Opsonic 

PiPET. 


Fig.  252. — Slide  Prepared  for  Making  Opsonic  Smears. 
A,  The  smearing  edge,  slightly  concave,  with  smooth,  sharp  edge. 


As  the  smears  are  made,  two  from  the  contents  of  each  pipet,  the  slides  are  num- 
bered in  duplicate,  and  are,  after  drying,  placed  in  a  saturated  solution  of  mercuric  chlorid 
for  from  two  to  five  minutes.  In  dealing  with  the  tubercle  bacillus  the  slides  are  then  stained 
with  carbolfuchsin,  hot,  for  two  minutes,  then  decolorized  in  2^  per  cent,  sulphuric  acid 
until  the  counting  edge,  where  the  leukocytes  are,  is  decolorized,  no  attention  being  paid 
to  the  condition  of  the  other  portion  of  the  smear.  If  it  is  desired  to  destroy  all  red  cells, 
leaving  nothing  but  a  line  of  leukocytes  extending  across  the  sHdc,  a  solution  of  4  per  cent, 
acetic  acid  is  poured  quickly  over  the  slide  and  immediately  rinsed  off.  This,  however,  is 
not  necessary.  The  slides  are  then  counterstained  with  aqueous  methylene-blue  for  two 
or  three  minutes,  washed  quickly,  and  dried  on  blotting-paper  at  once.  If  washing  is 
prolonged,  the  leukocytes  are  apt  to  become  decolorized,  so  that  their  borders  cannot  be 
w^ell  made  out.  In  dealing  with  organisms  other  than  tubercle  a  most  satisfactory  stain  is 
carbolthionin  blue.  One  or  two  minutes  is  ordinarily  sufficient  for  staining.  If  the  stain- 
ing is  properly  accomplished,  the  red  cells  will  be  of  light  green,  the  bacteria  of  deep 
purple,  and  the  protoplasm  of  the  leukocytes  lightly  stained. 

Counting.— The  total  number  of  bacteria  in   100  leukocytes  should  be  counted  in 


68o  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

each  preparation.  By  counting  groups  of  ten  cells  in  ten  different  portions  of  the  smear, 
a  better  average  is  obtained  than  would  be  if  loo  cells  were  counted  in  a  more  limited 
portion.  The  phagocytic  index,  so  called,  is  the  average  number  of  bacteria  contained  in 
each  leukocyte,  and,  therefore,  is  obtained  by  dividing  the  number  of  bacteria  counted  by 
the  number  of  cells.  The  phagocytic  index  is  thus  calculated  in  the  case  of  each  serum 
tested.  The  opsonic  index  represents  the  relation  between  the  phagocytic  index  of  a 
patient  and  the  phagocytic  index  of  the  normal  serum  or  sera.  To  arrive  at  the  opsonic 
index,  therefore,  the  phagocytic  index  of  the  patient's  serum  is  divided  by  that  of  the 
normal.  In  the  case  of  the  tubercle  bacillus,  the  normal  phagocytic  index  would  be  the 
average  of  those  obtained  in  the  three  or  four  normal  sera  tested.  In  the  case  of  other 
organisms,  the  phagocytic  index  should  be  that  of  the  pooled  normal  sera.  Supposing, 
then,  that  in  the  case  of  the  normal  serum  loo  leukocytes  have  ingested  200  bacteria,  the 
phagocytic  index  will  obviously  be  2.  In  case  of  the  patient's  serum,  supposing  that  100  leu- 
kocytes will  have  ingested  60  bacteria,  the  phagocytic  index  in  this  case  will  be  0.6.  The 
opsonic  index  would  equal  then  the  phagocytic  index  of  the  patient,  divided  by  the  normal 
phagocytic  index,  or  0.6  divided  by  2,  which  would  equal  0.3.  The  normal  index  being 
considered  unity,  the  patient's  serum  would  then  be  said  to  have  fo  of  the  normal  opsonic 
power. 


Fig.  253. — Making  an  Opsonic  Smear. 

The  technique,  as  detailed,  requires  certain  further  refinement  in  order  to  make  it 
possible  to  achieve  accurate  results.  In  regard  to  the  corpuscular  mixture,  it  is  absolutely 
necessary  that  the  red  cells  be  not  susceptible  to  agglutination  when  in  contact  vdth  other 
sera.  Consideration  will  show  that  if,  in  testing  a  certain  serum,  the  red  cells  come  in  con- 
tact with  it  and  become  agglutinated,  the  physical  properties  of  this  mixture,  so  far  as  the 
relation  of  the  bacteria  and  the  leukocytes  is  concerned,  will  differ  essentially  from  the  con- 
dition found  in  an  opsonic  mixture  in  which  the  red  cells  are  not  agglutinated.  If  this 
should  occur,  either  when  in  contact  with  the  patient's  serum  or  with  the  normal  serum, 
-  the  opsonic  indices  are  apt  to  show  gross  inaccuracies.  For  instance,  Fleming's  experi- 
ments have  shown,  citing  one  of  his  cases,  that  where  he  used  corpuscles  not  agglutinated 
by  either  the  patient's  or  the  control  serum,  the  opsonic  index  was  0.52,  but  using  corpus- 
cles which  the  patient's  serum  did  agglutinate,  the  opsonic  index  was  2.72.^  Constant  use 
in  the  laboratory  of  the  corpuscles  of  different  workers  -will  solve  the  question  as  to  whether 
or  not  they  are  satisfactory,  so  far  as  thpir  non-agglutinating  qualities  are  concerned.  The 
writer's  corpuscles  agglutinate  when  in  contact  with  some  sera,  and  hence  cannot  be  used 
for  opsonic  determinati;  n. 

Every  part  of  the  corpuscular  mixture  should  contain  an  equal  distribution  of  leuko- 
cytes.    Too  much  emphasis  cannot  be  laid  upon  the  importance  of  thorough  mixing  of 

^  Fleming,  Practitioner,  London,  May,  1907. 


THE   DETERMINATION    OF    THE    OPSONIC    INDEX  68 1 

the  corpuscles,  by  rolling  the  tube  between  the  palms  of  the  hands  frequently  if  the  cor- 
puscles are  to  be  used  over  a  long  period.  The  reason  is  that  if  in  the  smear  derived  from 
the  patient's  serum  few  leukocytes  are  to  be  found,  while  in  the  normal  a  satisfactory 
number  are  present,  the  phagocytic  index,  and,  of  course,  the  resulting  opsonic  index,  will 
be  greater  than  it  would  be  if  there  were  approximately  the  same  numbers  of  leukocytes  in 
each  smear. 

The  so-called  leukocytic  cream,  a  more  or  less  concentrated  layer  of  leukocjiies,  sup- 
posed to  remain  on  the  surface  of  the  corpuscular  mixtures  after  centrifugalization,  may 
perhaps  be  a  constant  feature,  but  as  sufficient  quantities  of  leukocj'tes  may  be  found  in 
any  portion  of  the  corpuscles  if  it  be  kept  thoroughly  mixed,  the  "cream"  should  be  left 
out  of  consideration.  Thorough  mixing,  then,  eliminates  this  source  of  error,  induced  by 
taking  up  various  numbers  of  leukocytes  from  a  mixture  in  which  they  are  unevenly  dis- 
tributed.    Fleming's  experiments  show  that  the  possible  error  is  from  20  to  50  per  cent. 

Emulsion. — In  the  case  of  all  organisms  but  the  tubercle  bacillus,  the  ideal  emulsion 
for  index  determination  is  one  of  sufficient  thickness,  so  that  the  average  number  taken  up 
by  each  leukocyte  shall  be  from  three  to  five.  In  the  case  of  the  tubercle  bacillus  a  count 
of  I  or  I J  per  leukocyte  is  to  be  aimed  at.  When  determining  a  large  number  of  opsonic 
indices  at  one  time  a  "trial  trip"  should  be  first  put  up  in  order  to  test  the  emulsion. 
If  there  are  very  many  clumps  of  bacteria,  or  if  the  phagocytic  count  is  so  high  that  count- 
ing will  be  too  laborious,  so  many  bacteria  being  taken  up  by  each  cell,  the  emulsion  must 
be  in  the  former  case  centrifugalized  or  further  broken  up  by  the  pipet,  or,  in  the  latter  case, 
diluted  with  salt  solution.  The  prime  requisite  for  accurate  work  is  a  good  emulsion. 
After  any  modification  of  the  emulsion  that  may  appear  necessary  after  the  first  trial  trip, 
a  second  test  should  be  made  to  see  if  the  emulsion  has  been  improved.  The  trial  trip 
will  also  tell  us  whether  the  corpuscles  are  good  or  not.  If  the  leukocytes  are  found  to  be 
clumped,  so  as  to  make  their  outlines  indefinite,  and  thus  possibly  hide  organisms  which 
should  be  counted,  new  corpuscles  should  be  prepared.  The  trial  trip  then  is  essential, 
since  it  tells  us  whether  our  emulsion  and  corpuscular  mixture  are  suitable  for  accurate 
work.  As  to  the  serum,  it  is  best  not  to  allow  it  to  stand  more  than  three  or  four  hours  at 
room-temperature  before  being  tested.  It  has  been  found  by  Fleming  {loc.  cit.)  that  the 
opsonic  power  of  the  blood,  standing  at  room-temperature,  is  subject  to  quite  wide  varia- 
tions between  the  fourth  and  twelfth  hour,  but  that  by  the  twelfth  hour  the  original  opsonic 
power  is  practically  always  regained  as  it  was  during  the  first  three  or  four  hours.  Extreme 
care  must  be  used  not  to  heat  the  serum  during  the  process  of  sealing  in  the  capsule,  other- 
wise great  inaccuracies  will  ensue. 

A  source  of  error,  pointed  out  by  Fleming,  that  should  be  avoided,  is  the  aspiration  of 
red  cells  from  the  blood  specimen  to  be  tested,  when  only  the  serum  should  be  drawn  into 
the  opsonic  pipet.  The  reason  is  that  the  opsonic  index  is  invariably  lowered  in  propor- 
tion as  increasing  amounts  of  red  cells  are  taken  into  the  pipet  with  the  serum.  This 
may  be  avoided  by  allowing  the  blood  to  clot  firmly  in  the  capsule,  or  by  centrifugalization 
before  using,  and  by  the  observance  of  great  care  to  prevent  the  tip  of  the  pipet  entering 
the  clot  and  taking  in  red  corpuscles. 

If  the  details  of  the  technique  are  carefully  followed  as  here  outlined,  and  the  sources 
of  error  are  appreciated  and  carefully  guarded  against,  after  a  little  experience  there  should 
be  no  greater  error  than  is  consistent  with  usefulness  of  the  opsonic  index  as  a  guide  for 
chnical  work.  By  study  of  a  large  number  of  indices  of  normal  individuals,  repeatedly 
determined,  in  Wright's  laboratory,  it  has  been  found  that  in  about  75  per  cent,  of  the 
determinations  the  index  falls  between  0.95  and  1.05,  a  variation  of  10  per  cent.  In  all  but 
a  few  of  the  regaining  25  per  cent,  the  indices  fell  between  0.90  and  i.io.  It  was  very 
unusual  to  find  the  index  of  an  individual  previously  determined  as  normal  to  at  any  time 
fall  below  0.90  or  above  i.io.     Variations  within  these  limits  are  apparently  unavoidable. 

Apart  from  these  possible  variations,  error  does  creep  into  the  work  frequently,  but  it  is 
generally  pcssil)ie  for  the  Icchnician  to  recognize  when  any  great  inaccuracy  has  occurred 


682 


THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 


by  scrutinizing  the  phagocytic  indices  of  the  normal  sera.  If  these  show  wide  variations 
in  the  average  number  of  cells  which  contain  phagocytes,  it  is  obvious  that  the  other  sera 
will  be  subject  to  the  same  variations.  The  basis  for  accurate  indices  is  a  stable,  constant 
normal. 

It  is  perfectly  ob\'ious  to  one  who  studies  the  sources  of  error  in  opsonic  technique, 
as  pointed  out  by  Fleming  and  referred  to  in  this  article,  that  accuracy  cannot  be  consist- 
ently achieved  unless  they  are  recognized,  and  it  would  seem  probable  that  herein  hes  the 
reason  for  the  inaccurate  results  of  so  many  laboratory  workers,  which  have  led  them  to 
discard  the  determination  of  the  opsonic  index  as  an  impracticable,  inaccurate,  and,  there- 
fore, unnecessary  procedure. 

AGGLUTINATION  TEST  (WRIGHT'S  METHOD) 

If  one  desires  to  determine  the  point  at  which  a  serum  will  agglutinate  typhoid,  colon, 
or  other  agglutinable  organisms  by  macroscopic  method,  and  is  able  to  blow  glass  sufl&- 


FiG.  255. — Wright's  Thbottled  Pipet. 
Applying  ring  of  sealing-u-:ix. 


ciently  well  to  make  a  throttled  pipet,  Wright's  method  is  ser\dceable.  The  procedure 
is  as  follows:  the  first  step  is  to  make  a  so-called  throttled  pipet  (Fig.  254).  A  piece  of 
|-inch  tubing  is  heated  in  a  biow-pipe  flame,  and  drawn  out  into  a  capillary  stem  about  J 


AGGLUTINATION    TEST    ( WRIGHT' S    METHOD) 


683 


in.  in  diameter,  and  this  is  cut  into  S-inch  lengths.  One  end  of  each  capillary  tube  is  heated 
in  the  pilot  flame  of  a  Bunsen  burner,  and  drawn  out  to  a  minute  capillary  hair,  which 
barely  admits  air  (Fig.  254).  Upon  the  proper  drawing  out  of  this  capillary  depends  the 
usefulness  of  this  pipet.  This  capillary  hair  may  be  from  ^  to  J  in.  long,  and  constitutes 
the  throttle.  A  collar  of  sealing  wax  is  applied^ to  the  capillary  J  in.  below  the  throttled 
portion  (Fig.  258);  a  piece  of  t?  in.  tubing  is  drawn  out,  and  is  broken  off  at  a  point  in  the 
taper  where  the  lumen  vnW  be  large  enough  to  admit  the  capillary.  Into  this  stub  the 
throttled  capillar)^  is  introduced,  open  end  foremost,  drawn  through  until  the  sealing  wax 


Fig.  256. — Wright's  Throttled  Pipet. 
Inserting  capillary  tube  into  stub. 


Fig.  257. — Wright's  Throttled  Pipet. 
Fixing  the  capillary  tube  in  the  stub  by  melting  wax  ring. 


Fig.  258.  —  Wrigect's 
Throttled  Pipet 
FOR  Agglutination 
Test. 

A,  Capillary;  B,  seal- 
ing-wax ring;  C,  throt- 
tle; E,  completed  pipet. 


reaches  the  narrow  portion  of  the  stub  (Fig.  256).  This  portion  is  then  carefully 
heated  and  the  sealing-wax  allowed  to  set.  The  next  step  is  to  test  the  throttle  as 
to  whether  it  may  or  may  not  admit  air.  To  do  this  collapse  a  rubber  teat  and  apply  to 
the  large  end  of  the  pipet.  If  the  teat  very  gradually  fills,  it  shows  that  the  throttling  is 
good.  If  it  does  not  fill,  the  throttle  is  not  perv-ious,  and  a  thin  wire  or  glass  tube  may  be 
inserted  into  the  stub  and  a  short  piece  cf  the  hair  throttle  cautiously  broken  off.  If  the 
hair  throttle  is  too  patent,  that  is,  if  the  teat  suddenly  fills  out,  the  throtiling  is  not  properly 
done  and  the  tube  is  useless,  because  it  will  be  inefficient  in  controlling  the  several  volumes 
of  fluid  which  it  is  to  contain. 


684 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


A  mark  is  placed  f  in.  from  the  end  of  the  tube  as  a  measure  of  volume.  For  a  Widal 
reaction  a  rather  thick  emulsion  (about  5,000,000,000  per  cc.)  of  living  typhoid  organisms 
is  made  by  washing  off  an  agar  grovi^th  with  a  0.85  per  cent,  salt  solution.  This  is  placed 
in  the  watch-glass  and  pipeted,  so  that  there  will  be  no  macroscopic  clumps.  The  patient's 
blood  is  drawn  in  the  same  manner  as  for  opsonic  work,  allowed  to  clot,  and  the  clear  serum 
used.     A  dish  of  0.85  per  cent,  solution  is  at  hand.     Four  slides  are  cleaned  with  watch- 


FiG.  259. — Method  of  Cleaning  Slides  with  Jeweler's  Emery  Paper. 

maker's  emery  paper  (Fig.  259),  and  wiped  with  a  clean  towel.  With  a  rubber  teat  affixed 
to  the  long  pipet,  a  series  of  seven  volumes  of  salt  solution  is  measured  off  and  drawn 
consecutively  into  the  pipet,  separated  by  air-bubbles.  Separate  volume  is  expressed  at 
either  end  of  each  of  these  four  slides,  except  in  the  first,  where  one  end  is  left  vacant. 
Two  volumes  of  serum  are  taken  into  the  same  pipet,  separated  by  bubble,  and  one  is 
expressed  at  the  yacant  end  of  the  first  slide.     The  second  volume  of  serum  is  intimately 


Fig.  260. — Technique  for  Agglutination  Test. 
Seven  equal  volumes  of  0.85  per  cent,  salt  solution  drawn  into- pipet,  separated  by  air-bubbles. 

mixed  with  the  volume  of  salt  solution  on  the  first  slide,  and  one  volume  is  extracted  from 
this  after  mixing,  and  added  to  the  first  drop  on  the  second  slide  again  after  mixing.  A  vol- 
ume is  extracted  from  this  drop  and  added  to  the  next,  and  so  on,  until  we  reach  the  seventh 
drop,  from  which  a  volume  is  discarded  after  mixing.  We  then  wash  out  the  pipet  in 
0.85  per  cent,  salt  solution  in  order  to  free  it  from  any  traces  of  serum.  We  then  have  on 
the  four  slides  one  volume  of  clear  serum,  six  separate  volumes  of  mixed  sera  and  salt 
solution,  and    finally  one   volume  of   salt  solution.      We  then  take  up  eight  separate  vol- 


THE    STERILIZATION   OF    VACCINES  685 

umes  of  the  bacterial  emulsion  with  air-bubbles  separating  the  volumes,  and  add  one  vol- 
ume to  each  dilution  or  drop  on  the  slide,  beginning  at  the  eighth  drop,  which,  as  we  shall 
remember,  consists  of  nothing  but  one  volume  of  salt  solution.  We  then  have  as  a  control 
equal  volumes  of  salt  solution  and  bacterial  emulsion.  To  each  of  the  follo^\ang  drops  we 
add  one  volume  of  emulsion,  thoroughly  mixing  each  time.  Then,  after  washing  out  the 
pipet  again,  to  free  it  from  all  traces  of  serum,  we  draw  into  the  pipet,  beginning  with 
the  control,  one  volume  from  each  dilution,  seal  the  end  of  the  tube,  and  place  in  the  incu- 
bator upright  for  one  hour  at  37°  C. 

It  will  be  seen  that  the  dilutions  are  as  follows — i  :  2,  i  :  4,  i  :  8,  i  :  16,  i  :  32,  i  :  64, 
I  :  128,  and  finally  the  control.  If  agglutination  is  positive,  it  will  be  possible,  with  the 
naked  eye,  to  note  the  clumping  of  the  bacteria  and  the  exact  dilution  at  which  the  clump- 
ing has  occurred. 

The  difiiculties  of  this  method  are  largely  those  associated  with  preparation  of  the 
pipet.  The  bacterial  emulsion  used  should  not  be  too  thick — about  5,000,000,000  per  cc, 
is  about  the  right  bacterial  content;  it  should  be  free  from  macroscopic  clumps. 

Killed,  organisms  may  be  used,  but  the  dilution  at  which  agglutination  will  take  place 
is  apt  to  be  lower  than  in  the  case  of  living  bacilli. 


Fig.  261. — Technique  for  .A.ggt.utination  Test. 

Expressing  volumes  of  salt  solution  on  slides.  ■• 

The  method  is  not  quite  so  delicate  as  the  microscopic,  in  that  in  the  latter  clumping 
may  occur  at  a  somewhat  higher  dilution.  Its  advantage  over  some  other  macroscopic 
methods  lies  in  the  fact  that  the  question  of  distinguishing  between  sedimentation  and 
agglutination  does  not  arise,  for  the  amount  of  settling  in  an  upright  capillary  tube  in  the 
one-half  hour  allowed  in  no  case  resembles  the  flocculent  condition  found  where  agglutina- 
tion has  taken  place. 

NOTE   CONCERNING  THE  STERILIZATION  OF  VACCINES 

At  the  present  time  the  only  method  that  can  be  recommended  for 
every-day  use  in  killing  bacteria  for  vaccines  is  the  use  of  heat.  The 
temperature  of  60°  C.  for  one  hour  can  Ije  depended  on  to  kill  any 
species  of  bacteria  which  are  at  present  used  in  the  preparation  of  \-ac- 
cine.     It  is  the  temperature  most  commonly  used. 

There  is  sufficient  evidence  that  this  amount  of  heating  injures  the 
vaccinating  qualities  of  certain  bacteria.     It  is,  therefore,  desirable  to 


686  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

subject  the  vaccine  to  as  short  an  exposure  as  possible  to  this  degree 
of  temperature.  In  the  case  of  staphylococcus  albus,  citreus,  colon, 
and  Friedlander's  bacillus,  exposing  in  a  water-bath  at  60°  C.  for  fifteen 
minutes,  and  immediately  following  the  addition  of  ^  of  i  per  cent,  (of 
the  total  bulk)  of  lysol,  has  been  found  sufficient  to  destroy  these  bacteria. 
In  the  case  of  staphylococcus  aureus,  however,  from  twenty  to  twenty- 
five  minutes  will  commonly  be  required.  In  the  case  of  gonococcus 
the  addition  of  ^  of  i  per  cent,  lysol  to  the  bacterial  emulsion,  thorough 
shaking,  and  exposure  to  a  temperature  of  37^°  C.  in  an  ordinary  in- 
cubator for  a  period  of  tAvelve  hours  have  been  found  to  kill  the  organ- 
isms. In  the  case  of  typhoid  the  present  method  of  sterilization  used 
in  Wright's  laboratory,  London,  is  exposure  to  a  temperature  of  53  °  C. 
for  seventy  minutes.  In  the  case  of  streptococcus  and  pneumococcus 
heating  for  thirty  minutes  is  ordinarily  sufficient.  In  all  cases 
it  is  wise  to  add  lysol  immediately  after  sterilization.  In  every  case 
the  vaccine  should  be  tested  culturally  to  prove  its  sterility.  Other 
methods  of  destroying  bacteria  in  the  preparation  of  vaccine  to  the 
end  of  rendering  it  a  more  efficient  immunizing  agent  will  be  discussed 
later. 


Clinical  Practice 
acute  fulminating  infections 

A  constant  protection  against  the  invasion  of  pathogenic  organisms 
is  the  unbroken  skin  in  health.  The  hair-follicles  and  the  openings  of 
the  sebaceous  and  sweat-glands,  however,  become  avenues  of  entrance 
for  bacteria  at  times  and  localized  infections  may  result.  Excessive 
activity  in  the  secretion  of  sebaceous  material  renders  the  skin  oily 
and  more  apt  to  harbor  bacteria  on  its  surface.  The  tendency  of  these 
glands  to  become  occluded,  resulting  in  the  formation  of  sebaceous 
cysts  and  comedones,  offers  opportunities  for  the  surface  bacteria  to 
grow  in  a  medium  which  is  more  or  less  out  of  contact  with  the  circulat- 
ing blood.  Thus  we  have  conditions  which  predispose  to  acne  and 
furunculosis.  A  perfectly  healthy  skin  is  more  or  less  proof  against 
such  infections,  unless  the  organisrns  be  inadvertently  rubbed  into 
these  minute  openings,  or  some  injury  impairs  the  blood-supply.  The 
observations  of  Da  Costa  would  indicate  that  the  predisposition  of  dia- 
betics to  furunculosis  is  dependent  upon  a  habitually  low  opsonic 
power.  It  would  seem  that  the  tendency  to  skin  infection,  seen  after 
exhausting  fevers,  is  partly  due  to  a  deficiency  of  the  blood-stream  in 
its  content  of  antibacterial  substances.     Predisposing  factors,  therefore, 


ACUTE   FULMINATING   INFECTIONS  687 

to  skin  infection  are  certain  conditions  of  the  skin  itself,  and  in  some 
cases  in  all  probability  some  deficiency  in  the  antibacterial  power  of  the 
blood-stream. 

Infections  taking  place  through  the  normal  openings  of  the  skin 
are  commonly  localized.  We  have,  as  a  result,  acne  and  furunculosis. 
This,  however,  depends  largely  on  the  virulence  and  character  of  the 
infecting  organisms.  When  lymphangitis  and  temperature  develop, 
the  infection  may  be  termed  acute  and  fulminating  in  type,  because 
in  these  cases  the  bacteria  are  unquestionably  being  taken  into  the 
blood-stream.  The  most  serious  of  these  fulminating  infections  are 
obviously  those  which  originate  from  the  entrance  of  bacteria  through 
some  traumatic  break  in  the  skin.  The  most  common  and  least  serious 
under  ordinary  conditions  are  those  due  to  the  staphylococcus.  The 
graver  infections  result  from  the  entrance  of  streptococcus,  pneumococcus, 
and  occasionally  to  some  other  bacteria.  The  gravity  of  the  infection 
depends  upon  the  number  of  organisms  that  gain  entrance,  the  depth 
to  which  they  penetrate,  and  the  character  of  the  tissues  in  which  they 
find  their  initial  seat.  It  is  obvious,  if  large  numbers  of  virulent  bacteria 
suddenly  find  their  entrance  into  the  subcutaneous  tissue,  they  will  find 
opposed  to  them  only  few  leukocytes  and  only  a  certain  quantum 
of  lymph.  Although  certain  of  the  bacteria  may  be  destroyed  at  once, 
an  excess  of  organisms  will  immediately  absorb  the  antibacterial  sub- 
stances that  are  at  the  locus  of  entrance.  Trauma  to  the  tissues  at  this 
point  and  a  lymph  of  lowered  antibacterial  power  w^ould  furnish  a  good 
medium  on  which  bacteria  which  are  not  killed,  will  find  more  or  less 
unbridled  opportunity  for  growth.  Swelling  of  the  tissues  from  exuda- 
tion, destruction  of  leukocytes  and  tissue-cells,  due  to  the  virulence 
and  numbers  of  the  organisms,  may  be  conceived  to  inhibit  the  satis- 
factory outcome  in  the  reaction  of  inflammation  in  its  attempt  to  bring 
large  amounts  of  blood  and  leukocytes  into  contact  with  the  bacteria 
in  the  focus,  and  lead  to  their  destruction.  Where  the  bacteria  entering 
are  in  large  numbers,  some  are  taken  into  the  circulation  at  once,  and 
the  antibacterial  power  of  the  blood  may  be  temporarily  lowered,  and 
thus  render  the  blood-stream  itself  less  efficient  than  it  normally  was. 

If  the  locus  of  infection  be  superficial,  tissue  necrosis  may  take  place 
in  such  a  manner  that  the  pus  may  point,  and  either  evacuate  itself  or 
be  readily  evacuated  by  surgical  procedure;  further  applications  of 
heat  will  be  efficient  in  inducing  a  more  free  blood-supply.  The  deep 
infection  may  be  beyond  the  scope  of  ordinary  therapeusis.  Any  collec- 
tion of  fluid  which  later  will  develop  will  necessarily  be  under  greater 
tension;   excessive  autoinoculation  will  be  apt  to  take  place,  because  of 


688  THERAPEUTIC   IMMUNIZATION    AND    VACCINE   THERAPY 

this  tension  and  of  the  impossibihty  of  the  pus  to  discharge  itself.  We 
have  considered  previously  the  characteristics  of  the  pus  of  pyogenic 
bacteria,  and  have  noted  that  it  has  a  distinct  tendency  to  dissolve 
connective  tissue  on-  account  of  the  tryptic  ferment  it  contains.  In  a 
deep  infection  this  solution  of  tissues  will  take  place  in  all  directions 
under  excessive  tension. 

If  infection  enters  a  tendon-sheath,  there  is  nothing  to  prevent  a 
severe  infectious  process,  as  the  conditions  are  such  in  these  sheaths 
as  to  prevent  any  rapid  replacement  of  lymph,  exhausted  of  its  anti- 
bacterial power,  by  fresh  lymph  from  the  blood  and  leukocytes.  The 
same  may  be  said  of  serous  cavities,  such  as  the  joints.  There  are  but 
two  types  of  localized  infection  which  can  be  treated  successfully  by 
specific  antitoxins.  They  are  diphtheria  and  tetanus.  Success  in  the 
treatment  of  the  former  depends  on  the  addition  of  antitoxin  during 
the  early  period  of  the  disease,  before  it  has  appeared  in  the  normal 
course  of  events  in  the  blood.  The  success  in  the  treatment  of  tetanus 
by  antitoxin  is  nowhere  near  so  great.  In  order  to  be  efficient  it  must 
be  administered  immediately  after  infection  has  taken  place,  in  large 
doses,  at  least  every  eight  up  to  twelve  hours.  The  use  of  antitoxin  in 
diphtheria  and  tetanus,  in  that  it  comes  to  the  assistance  of  the  immuniz- 
ing mechanism  at  a  point  where  it  is  deficient,  furnishes  perhaps  the 
most  striking  example  of  a  system  of  therapeusis  which  endeavors  to 
make  use  of  the  body's  own  methods  in  the  cure  of  disease.  In  other 
localized  infections  we  have  no  such  efficient  treatment. 

In  the  treatment  of  superficial  fulminating  infections,  in  their  very 
early  stages,  clinical  practice  appears  to  be  overwhelmingly  in  favor 
of  the  application  of  heat  by  poultices  and  hot  soaks  where  they  can  be 
applied.  The  application  of  these  measures  is  unquestionably  the  first 
indication,  for  the  reason  that  it  tends  to  further  the  efficiency  of  the 
process  which  the  body  first  makes  use  of  in  its  struggle  against  infec- 
tion, in  that  it  increases  the  supply  of  blood  to  the  part  and  thus  aids  in 
rendering  conditions  in  the  focus  of  infection,  so  far  as  opsonin  and 
leukocytes  are  concerned,  as  nearly  like  that  to  be  found  in  the  circulating 
blood  as  possible.  It  is  a  rational  procedure,  because  it  tends  to  render 
more  effective  the  initial  protective  reaction  of  the  immunizing  mechan- 
ism. Any  therapeutic  measure  which  might  inhibit  in  any  way  the 
initial  hyperemic  reaction  must  be  considered,  on  the  grounds  stated,  an 
improper  procedure.  Bier's  passive  hyperemia  and  Gamgee  dressings 
are  instances  of  therapeutic  measures  misapplied  if  used  at  this  early 
stage  of  the  infection.  They  induce  a  condition  of  stasis  of  circulation 
in  the  infected  focus,  whereas  the  clear  indication  is  a  rapid  interchange 


ACUTE    FULMINATING   INFECTIONS  689 

of  lymph  into  and  out  of,  the  focus,  and  a  continuous  supply  of  fresh 
leukocytes,  such  as  active  hyperemia  brings  about.  (See  Principles  of 
Immunization.) 

Although  any  measure  to  obstruct  free  hyperemia  is  thoroughly 
irrational  in  general,  superficial  infections,  in  which  the  blood-supply 
appears  to  be  deficient,  particularly  when  the  infection  is  of  very  slight 
dimension,  may  be  sometimes  excepted.  In  some  of  these  cases  inter- 
mittent passive  hyperemia,  as  described  on  p.  232,  would  appear  more 
advantageous  than  an  endeavor  to  increase  hyperemia  by  heat.  This 
is  seen  in  slight  infections  of  the  fingers. 

Where  the  infected  area  is  large,  as  in  phlegmon,  passive  hyperemia 
may  be  decidedly  dangerous,  because  the  blood-stream  may  receive  exces- 
sive autoinoculation  from  the  lymph  which  has  been  forced  throughout 
the  infected  area,  and  has  been  taken  into  the  blood  again  bearing  ex- 
cessive numbers  of  bacilli.  By  such  a  misapplied  measure  we  not  only 
inhibit  the  normally  efficacious  active  hyperemia,  but,  by  the  excessive 
autoinoculation,  we  tamper  with  the  blood-stream  and  lower  its  anti- 
bacterial efficiency. 

Bier's  suction  intermittently  applied,  if  the  infected  area  be  small, 
may  be  of  value  in  that  it  brings  the  serum  into  more  intimate  contact 
with  the  infected  focus  than  might  otherwise  be  the  case.  It  still  does 
not  prevent,  if  it  is  not  applied  too  often,  frequent  interchange  of  the 
serum  with  that  from  the  blood,  an  interchange  of  lower  for  higher 
antibacterial  efficiency. 

The  use  of  vaccines  at  this  stage,  even  supposing  that  accurate 
bacteriologic  diagnosis  can  be  readily  made,  is  generally  contra- 
indicated,  because  the  failure  of  the  body  to  immunize  itself  is  not  due 
to  any  deficiency  in  bacterial  stimulus. 

The  breaking  down  of  the  tissues,  the  formation  of  a  pus-pocket, 
attest  the  failure  of  the  initial  attempt  to  destroy  the  bacteria.  We  have 
seen  that  pus  under  pressure  not  only  furnishes  conditions  favoral^le 
to  local  growth  of  bacteria,  but  also,  by  its  tryptic  ferment,  leads  to  the 
spread  of  the  infection  by  solution  of  the  connective  tissue.  Further, 
as  a  corollary,  the  blood-stream  itself  is  forced  to  receive  more  or  less 
continuous  autoinoculation,  which,  if  excessive,  lowers  its  antibacterial 
efficiency.     The  indication  here  met  is  to  eliminate  autoinoculation. 

At  this  point,  surgical  measures  have  always  found  their  rational 
application,  and  remo\-ing  the  pus,  relieving  the  pressure,  nullifying 
the  tendency  of  the  infection  to  spread,  and  allowing  fresh  lymph  from 
the  blood  to  take  the  place  of  lymph  which  has  lost  its  antibacterial 
power  by  its  long  contact  with  bacteria.  The  fresh  lymph  not  only 
44 


690  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

exerts  its  effect  against  the  bacteria,  but  'neutralizes  the  tryptic  ferment 
of  the  pus  and  prevents  further  solution  of  the  tissue. 

The  indication  next  is  to  perpetuate  such  conditions  as  may  produce 
a  continuously  fresh  circulation  of  lymph  through  the  walls  of  the  ca\ity 
and  out\vard  as  a  discharge.  Coagulation  of  lymph  in  the  walls  of  the 
ca^ity  unfortunately  prevents  such  free  discharge.  The  usual  measures 
of  using  wicks  as  drains  have  done  more  harm  than  good  in  most  cases, 
because,  instead  of  lending  toward  a  free  discharge,  they  have  pre^•ented 
discharge. 

One  of  the  most  important  and  efficient  therapeutic  measures  that 
have  been  offered  in  the  treatment  of  localized  infections  A^'right  has 
given  us  in  the  sodium  citrate  and  chlorid  solution  which  he  ad\'ises. 
This  solution  is  composed  of  4  per  cent,  sodium  chlorid  and  i  per  cent, 
sodium  citrate  in  water.  It  is  used  as  an  irrigation  and  as  a  constant 
dressing  in  the  case  of  abscesses  and  infected  wounds.  Its  action,  as 
has  been  pre\iously  stated,  by  means  of  its  sodium  citrate  content,  is 
to  decalcify  the  lymph  and  prevent  its  clotting  in  the  walls  of  the  cavity, 
to  prevent  the  formation  of  crusts  in  the  same  manner ;  and  of  the  salt 
content,  in  that  it  furnishes  a  hypertonic  solution,  to  induce  a  flow 
of  lymph  from  the  tissues  into  the  abscess  ca\ity.  Thus,  by  the  constant 
application  of  this  solution  after  operative  procedure,  free  circulation 
of  fresh  lymph  is  secured  and  maintained  in  the  focus.  When  this 
solution  is  used,  wicks  become  totally  unnecessary;  an  exception  may 
be  found  in  the  case  of  wounds  which  mechanically  close  themselves 
and  obstruct  the  exit  of  fluid.  In  this  case  rubber  dam  should  be  used 
for  its  mechanical  effect  in  keeping  the  wound  open. 

Contraindication  to  sodium  citrate  and  salt  solution  is  to  be  found 
in  cases  where  there  is  a  tendency  to  hemorrhage. 

The  salt  content  of  this  solution  is  very  irritating  to  the  skin,  and 
may,  if  necessary,  be  diminished  to  a  2  per  cent,  solution.  The  skin 
should  always  be  protected  by  means  of  boric  ointment,  in  order  to 
prevent  pustulation,  which  may  result  from  irritation  of  the  salt.  The 
use  of  sodium  citrate  and  chlorid,  therefore,  has  a  distinct  place  in  a 
system  for  immunization  in  localized  infections,  in  that  it  renders  efficient 
the  immunizing  mechanism  of  the  body  at  a.  point  where  it  most  com- 
monly fails.  The  writer  has  used  this  solution  exclusively  in  the  past 
three  years  to  fulfil  the  indication  as  here  stated,  and  has  found  it  to  be 
quite  as  efficient  as  theoretic  considerations  would  indicate. 

Its  consistent  efficiency,  contrasted  with  the  almost  total  inefficiency 
and  positive  harm  of  strong  antiseptics  in  the  treatment  of  these  condi- 
tions, should  lead  to  its  general  adoption,  or  to  the  adoption  of  some 


CULTURE  AT  TIME  OF  OPERATION  69I 

Other  solution  which  may  be  found  equally  good  or  better,  in  fulfiling 
that  essential  postoperative  requirement;  namely,  that  free  and  continuous 
circulation  of  lymph  into  the  focus  of  infection  must  he,  so  far  as  possible, 
maintained,  to  the  end  of  destroying  bacteria  by  nature^s  on'n  method. 

In  association  with  the  sodium  citrate  and  chlorid  solution  it  may  be 
advisable,  in  some  cases,  to  make  use  of  Bier's  suction,  where  it  can 
be  applied,  to  produce  a  more  searching  lymph  circulation.  This 
measure  has  been  rarely  necessary  in  the  writer's  experience. 

Ha\ing  secured  by  surgical  measures  the  evacuation  of  pus  and 
consequent  elimination  of  excessive  autoinoculation,  by  means  of  the 
citrate  and  salt  solution  the  maintenance  of  free  drainage,  and  conse- 
quent furtherance  of  conditions  necessary  for  destruction  of  the  bac- 
teria, we  ha\-e  next  to  consider  the  condition  of  the  blood-stream  as 
to  its  antibacterial  eflSciency.  Following  the  elimination  of  autoinocu- 
lation, the  opsonic  power  of  the  blood  rises  sooner  or  later  to  above 
normal.  If  the  opsonic  power  maintains  itself  above  normal,  such 
may  be  taken  as  evidence  of  a  proper  immunizing  response  to  bacterial 
stimulus.  Clinical  evidence  of  such  a  favorable  response  is  to  be  seen 
in  the  subsidence  of  local  and  general  symptoms  and  improvement  in 
local  conditions.  Vaccine  may  be  reasonably  withheld  so  long  as  the 
conditions  suggest  that  the  immunizing  response  is  sufficient.  In  the 
majority  of  cases  incision,  coupled  with  maintenance  of  free  drainage  by 
the  use  of  citrate  and  salt  solution,  is  followed  by  resolution.  In  those 
cases  that  do  not  readily  clear  up,  opsonic  determinations  generally  in- 
dicate a  low  antibacterial  power  of  the  blood-stream.  Consideration 
shows  that  the  surgical  measures  have  changed  what  bade  fair  to  be- 
come a  generalized  infection  into  a  localized  process.  Autoinoculation 
has  been  entirely  eliminated,  and  the  blood  recei\-es  no  impulse  leading 
to  the  production  of  specific  antibodies.  Hence  we  should  furnish  the 
stimulus  by  injection  of  corresponding  vaccine.  The  failure  of  these 
processes  'to  resolve  is  sufficient  reason  for  the  exhibition  of  vaccine 
without  resorting  to  opsonic  determinations. 

In  every  localized  infection  a  culture  should  be  obtained  at  the  time  of 
operation,  not  only  for  record  as  to  the  nature  of  the  infection,  but  also  to 
enable  one  to  furnish  a  vaccine  if  later  needed. 

Vaccine  is  indicated  when  these  processes  give  evidence  of  becoming 
indolent,  to  take  the  place  of  autoinoculation,  which  is  found  to  be  lacking 
in  such  conditions.  Vaccine  should  be  withheld  until  it  is  evident 
that  the  beneficial  effects  of  previous  autoinoculation,  either  natural  or 
induced  by  the  operative  procedure,  have  worn  off.  Indolence  of  the 
lesion  may  be  taken  to  indicate  this  state  of  affairs. 


692  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

Where  temperature  persists,  it  usually  means  that  there  is  some 
pocket  that  has  not  been  drained.  If,  in  spite  of  apparent  good  drainage, 
temperature  persists  irregularly,  whatever  autoinoculation  that  may  be 
responsible  for  the  temperature  is  probably  not  efficient  in  the  produc- 
tion of  antibodies.  In  such  cases  vaccine  should  be  given  regularly, 
with  the  hope  of  producing  a  continuous  elevation  in  the  opsonic  power. 

The  dosage  must  be  small,  eliminating,  so  far  as  possible,  the  period 
of  negative  phase — therefore,  frequent.  In  the  case  of  streptococcus  and 
pneumococcus  initial  dosage  of  from  2,000,000  to  5,000,000;  colon, 
10,000,000;  staphylococcus,  25,000,000,  should  be  injected  daily  and 
gradually  increased  by  from  2,000,000  to  10,000,000,  always  avoiding 
any  increase  in  temperature  or  subjective  symptoms.  As  the  dosage 
is  increased,  a  greater  period  must  elapse  before  the  next  is  given. 

Satisfactory  response  is  indicated  by  a  drop  in  temperature.  If 
temperature  does  not  fall  within  the  next  twelve  hours,  and  if  the  patient 
shows  no  signs  of  increased  toxemia,  the  dose  may  be  guardedly  in- 
creased. 

Where  the  infection  produces  no  temperature,  but  is  indolent  in 
resolution,  larger  doses  may  be  given  from  the  first,  as  the  lesion  now  has 
the  characteristics  of  a  localized  infection.  The  initial  dosage  of  pneu- 
mococcus and  streptococcus  may  be  10,000,000,  increased  by  the  same 
amount  two  days  later,  and  gradually  increased  further  up  to  100,000,000 
or  more  every  three  or  four  days.  The  other  local  measures,  as  suggested, 
to  cause  determination  of  the  blood  to  the  focus,  must  be  used.  Initial 
dose  of  staphylococcus  maybe  from  50,000,000  to  100,000,000;  of  colon, 
10,000,000  to  20,000,000.  The  smaller  doses  in  these  cases  may  be 
repeated  every  t^vo  days,  the  larger,  every  three  or  four  days.  Every 
dose  should  be  allowed  to  exert  its  full  effect  before  the  next  is  given. 
Opsonic  index  determinations  furnish  evidence  as  to  the  time  when  the 
effect  of  a  dose  of  vaccine  is  wearing  off. 

The  suggestions  here  offered  as  to  dosage  are  based  on  study  of  re- 
quirements by  means  of  the  opsonic  index;  generalized  reaction,  asso- 
ciated with  fever  following  vaccine,  in  the  localized  infections,  may 
take  place  if  too  large  dosage  be  given.  This  indicates  that  living 
bacteria  are  in  the  blood-stream,  and  that  conditions  favoring  spread 
of  the  infection  have  been  produced.  This  condition  should  be  entirely 
avoided,  and  can  be  if  the  dosage  be  increased  very  gradually. 

In  the  absence  of  generalized  reaction  following  vaccine  we  have 
local  evidence  in  an  increased  discharge,  swelling,  tenderness,  etc., 
that  the  dosage  is  too  large.  The  writer  has  made  it  a  point,  in  the 
exhibition  of  vaccine,  to  seek  to  avoid  any  local  or  general  reaction. 


GENERALIZED   INFECTIONS  693 

In  that  excellent  therapeutic  effect  may  be  produced,  ^vith  total  absence 
of  toxic  symptoms  or  local  exacerbation,  except  in  rare  cases,  the  writer's 
experience  entirely  corroborates  that  of  Wright. 

Treatment  of  deep  punctured  wounds  should  be  surgical,  and  should 
not  be  delayed,  particularly  if  tendon-sheath  involvement  is  suspected. 
The  development  of  pus  should  not  be  awaited.  The  other  measures 
referred  to  should  then  be  applied  as  indicated  to  induce  determination 
of  blood  to  the  lesion. 

In  all  cases  an  infected  member  should  be  held  in  an  elevated  or 
horizontal  position,  in  order  that  there  may  be  no  obstruction  to  the 
free  return  of  venous  blood,  to  the  end  of  securing  free  interchange  of 
blood  fluids. 

In  the  writer's  experience,  the  use  of  vaccine  when  the  acute  infections 
have  become  indolent  has  fulfilled  a  distinct  indication,  and  has  been 
followed  by  excellent  results  in  the  majority  of  cases  treated.  There 
has  been,  apparently,  no  advantage  gained  when  vaccines  have  been 
used  during  the  acute  febrile  period.  Vaccine  has  seemed  to  be  less 
efficient  in  streptococcic  infections  than  in  others.  The  results  have 
improved  since  the  adoption  of  better  methods  for  sterilizing  the  vaccine. 

Vaccine  should  be  prepared  from  cultures  obtained  from  the  patient 
if  possible.  Until  such  can  be  prepared,  corresponding  stock  vaccines 
should  be  used. 

Some  most  striking  results  have  been  obtained  in  treatment  of  infected 
laparotomy  wounds,  when  the  colon  bacillus  has  been  the  causal  agent. 
A  type  of  this  case,  treated  by  the  writer,  is  a  girl  of  ten  years,  who  for 
two  months  after  appendectomy  had  a  septic  temperature,  associated  with 
a  fistulous  opening  discharging  pus  and  feces.  Reoperated  twice,  in  search 
for  some  undischarged  pocket  of  pus,  but  none  was  found.  When  seen,  the 
patient  was  much  emaciated,  was  unable  to  retain  food  by  mouth,  was  running 
an  elevated  temperature,  discharging  feces  and  much  pus  from  the  operative 
wound.  A  bad  prognosis  had  been  given.  The  colon  bacillus  was  isolated 
from  the  pus  and  vaccine  injected  as  follows:  First  day,  10,000,000;  second, 
20,000,000;  fourth,  40,000,000;  fifth,  80,000,000.  The  temperature  had 
begun  to  drop  after  the  second  dose,  and  at  the  end  of  a  week  became  normal 
and  remained  so.  Discharge  of  pus  ceased;  the  child  was  able  to  take  food 
by  mouth.  Some  weeks  later,  after  the  fecal  fistula  had  closed,  patient  was 
discharged  well. 

GENERALIZED  INFECTIONS 
The  Septicemias. — Septicemias  may  be  divided  into  two  classes: 
first,  those  which  derive  their  bacteria  from  some  active  focus  of  infec- 
tion, such  as  uterine  sepsis;    and,  second,  those  in  which  the  bacteria 


694  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

appear  to  be  cultivating  themselves  in  the  blood-stream,  or  cultivating 
themselves  in  some  part  of  the  endarterial  system,  as  in  malignant  endo- 
carditis. In  the  first,  there  is  a  condition  of  more  or  less  continuous 
autoinoculation,  and  possibly  also  growth  of  bacteria  in  the  blood  itself; 
in  the  second,  the  preponderance  of  growth  of  bacteria  appears  to  be 
in  the  blood. 

In  the  first  class  we  must  include  acute  fulminating  infections  when 
associated  with  temperature,  and  likewise  carbuncle,  phlegmon,  erysipe- 
las, uterine  sepsis,  and  other  infections  which  start  locally,  but  which 
are  characterized  by  continuous  or  intermittent  autoinoculation;  in  the 
second  class  would  naturally  be  included  those  septicemias  in  which 
the  atrium  of  infection  is  not  demonstrable  or  in  which  the  locus  of 
infection  cannot  be  extirpated  or  drained. 

At  once  the  difference  in  prognosis  between  these  t\vo  classes  of  cases 
is  apparent,  when  we  consider  that  in  the  former  it  is  possible  commonly, 
by  means  of  operative  measures,  to  eliminate  autoinoculation  in  varying 
degree,  and  thus  diminish  the  numbers  of  bacteria  that  are  being  sent 
into  the  blood-stream,  while  in  the  latter,  the  true  septicemias,  we  have 
no  control  over  autoinoculation,  because  it  appears  the  bacteria  find  in 
the  blood-stream  a  suitable  medium  for  growth,  or  continually  find 
entrance  froni  some  focus  that  cannot  be  eradicated,  as,  for  instance, 
vegetations  in  the  endocardium. 

In  septicemia  dependent  on  local  infections  the  fact  of  the  immediate 
amelioration  in  symptoms,  drop  in  temperature,  and  disappearance  of 
bacteria  in  the  blood-stream,  after  operation,  indicates  that  the  blood- 
stream has  the  inherent  power  of  destroying  the  bacteria  present,  pro- 
vided that  constantly  new  invasions  of  bacteria  from  the  focus  of  infec- 
tion be  inhibited.  It  suggests  that  the  presence  of  bacteria  in  the 
blood-stream  is  largely  due  to  autoinoculation,  and  that  if  growth  does 
occur  in  the  blood-stream  itself,  it  may  be  accounted  for  by  diminished 
antibacterial  power,  produced  by  a  combination  of  antibacterial  sub- 
stances as  soon  as  they  enter  the  blood-stream  with  the  bacteria  already 
present. 

We  have  obviously  no  control  over  the  bacterial  content  of  the  blood 
in  the  true  septicemias,  save  by  making  use  of  measures  to  increase  the 
power  of  the  blood-stream  itself  to  destroy  the  bacteria. 

Uterine  Sepsis  and  Similar  Conditions.— Treatment  should 
be  directed  first  to  the  elimination  of  autoinoculation  by  absolute  rest  and 
such  local  measures  as  may  cause  free  drainage.  By  such  methods, 
abstraction  of  antibacterial  substances  from  the  blood-stream,  by  con- 
tinued fresh  invasion  of  bacteria,  will  be  lessened.     Fresh  increments 


SEPTICEMIA  695 

of  antibodies  in  the  blood-stream,  instead  of  being  immediately  absorbed 
by  the  bacteria,  will  be  applied  in  the  circulating  blood  against  the 
bacteria  in  the  focus  and  lead  to  its  final  localization. 

The  clinical  result  of  these  methods  is  indicative  of  their  advantage, 
and  lead  to  the  supposition  that  these  theoretic  considerations  are  not 
very  much  in  error. 

Where  temperature  persists  after  these  procedures,  opsonic  index 
determinations  have  shown  that  autoinoculation  has  not  been  thoroughly 
eliminated.  The  continuance  of  symptoms  and  temperature  shows 
that  the  autoinoculation  is  not  effective  in  the  production  of  sufficient 
antibodies  to  destroy  the  bacteria  that  enter  the  blood,  that  the  focus 
has  not  become  localized.  If  it  is  impossible  to  secure  better  drainage, 
the  next  indication  is  to  endeavor  to  fortify  the  blood-stream  by  means 
of  bacterial  vaccines. 

The  rationale  of  vaccine  at  this  point  has  been  considered.  It  should 
be  reiterated  that  what  evidence  there  is  at  hand  is  strongly  in  favor 
of  the  supposition  that  the  blood-stream  is  merely  the  carrier  of  the 
antibacterial  forces  of  the  body,  and  that  protective  substances  are 
derived  largely  from  some  other  tissue.  It  has  been  shown  by  Wasser- 
mann  and  others,  cited  by  Noon,^  that  inoculation  of  vaccine  into  the 
blood-stream  of  rabbits  temporarily  lessens  the  normal  production  of 
opsonin,  whereas  if  the  same  dose  is  inoculated  subcutaneously,  no 
negative  phase  or  diminution  in  opsonic  power  is  produced.  The 
obvious  explanation  must  be  that  vaccine  is  temporarily  localized  in 
the  tissues  and  absorbed  into  the  circulation  gradually  and  in  too  small 
quantities  to  deprive  it  of  much  of  its  antibacterial  substance.  It  would 
follow  naturally  that  subcutaneous  inoculation  will  minimize  the  risk 
of  lowering  the  opsonic  power  of  the  blood-stream.  It  was  found,  in 
addition,  that  the  rise  in  opsonic  power  following  negative  phase  does  not 
differ  much  in  either  of  these  methods  of  inoculation.  If  minute  dosage 
of  vaccine  subcutaneously  is  not  followed  by  negative  phase,  and  if  the 
same  dose  does  produce  diminished  resistance,  if  inoculated  intravenously, 
this  suggests  that  the  effect  upon  the  immunizing  mechanism  in  reducing 
its  efficiency  depends  upon  whether  or  not  the  quantum  of  vaccine  is 
taken  at  once  into  the  blood-stream.  Finally,  inasmuch  as  the  larger 
the  dose  injected  subcutaneously,  the  greater  the  amount  of  vaccine 
that  will  be  immediately  taken  up  into  the  blood-stream,  it  is  ob^ious 
the  larger  the  dose  inoculated,  the  greater  will  be  the  diminution  in  the 
antibacterial  power  of  the  blood  induced  by  it. 

In  treating  septicemias  we  cannot  afford,  even  for  a  few  hours,  to 

^  Brit.  Med.  Jour.,  August  28,  1909. 


696  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

break  down,  in  the  smallest  degree,  or  maintain  in  a  condition  of 
depression,  any  barrier  offered  against  the  growth  of  bacteria.  We, 
therefore,  have  immediate  reason  for  the  use  of  sufiSciently  small  dosage 
to  cause  complete  elimination  of  the  negative  phase  or  phase  of  dimin- 
ished resistance.  In  the  giving  of  vaccines  in  febrile  cases  it  is  the  desire 
to  produce,  by  subcutaneous  inoculation,  a  reaction  followed  by  raised 
immunity  and  no  preceding  negative  phase.  This  is  particularly  the 
case  in  septicemias.  The  best  way  to  prevent  the  taking  of  large 
amounts  of  vaccine  into  the  circulation  is  by  reducing  the  dosage. 
The  opsonic  index  has  provided  a  method  for  testing  the  effect  of 
inoculation,  and  by  its  use  it  was  found  possible  to  produce  an  im- 
mediate reaction  in  the  production  of  antibacterial  substances  without 
any  previous  diminution.  Wright  has  shown  it  possible  in  tubercu- 
losis to  produce  a  rise  in  opsonic  power  within  one  hour  after  inocu- 
lation. Haffkine,  referred  to  by  Wright,^  was  the  first  to  obtain  a 
condition  of  immunity  t^venty-four  hours  after  inoculation  of  plague 
vaccine.  Wright  later  showed  the  same  was  possible,  using  a  typhoid 
vaccine. 

Based  on  the  supposition  that,  in  spite  of  the  fact  that  the  blood- 
stream contains  toxic  numbers  of  bacteria  and  toxic  substances  in  large 
amount,  these  do  not  furnish  a  sufficiently  concentrated  stimulus,  because 
they  are  diluted  by  the  whole  blood-stream,  to  the  cells  responsible  for 
the  formation  of  antibacterial  substances,  we  are  justified  in  expecting 
that  a  concentrated  dose  of  vaccine,  incorporated  in  the  subcutaneous 
tissue,  might  be  efficient  at  this  point. 

That  it  is  possible  in  septicemia  to  induce  a  rise  in  the  opsonic  power 
of  the  blood  without  any  previous  induction  of  negative  phase  we  have 
a  sufficiency  of  laboratory  evidence.  This  rise,  however,  is  necessarily 
fleeting,  and  the  stimulus  in  the  way  of  vaccine  must  be  repeatedly  and 
frequently  given. 

Wright^  mentions  one  case  of  malignant  endocarditis  in  which  complete 
cure  was  achieved.  A  second  case  of  the  same  type,  associated  with  high 
temperature  for  three  months  before  vaccine  therapy  was  resorted  to,  devel- 
oped a  normal  temperature  following  inoculations,  but  death  followed  as  a 
result  of  cardiac  complications.  In  both  these  cases  careful  opsonic  deter- 
minations showed  a  satisfactory  immunizing  response  registered  by  a  rise 
in  the  opsonic  power.  Three  other  cases  of  malignant  endocarditis  (strepto- 
coccus) in  which  the  patients  died.  These  cases,  however,  showed  no  satisfac- 
tory immunizing  response  to  the  inoculation,  as  judged  by  the  rise  in  the  opsonic 

^  Lancet,  August  24,  1907.  ^  Ibid.,  August  24,  1907,  p.  499. 


GENERALIZED    INFECTIONS  697 

power.  He  refers  to  those  cases  of  Malta  fever  in  which  the  course  of  the 
disease  was  favorably  influenced,  the  clinical  improvement  associated  in  each 
case  with  an  increased  development  of  antibacterial  substances  in  the  blood. 
In  the  treatment  of  14  cases  of  malignant  endocarditis  Rosenow^  showed 
that  the  opsonic  index  was  generally  normal  or  above  at  first,  but  toward  the 
fatal  termination  of  the  disease  it  generally  fell  far  below  normal.  He  found 
that  injections  of  vaccine  were  followed  in  from  twenty-four  to  forty-eight 
hours  by  a  rise  in  the  opsonic  index.  He  found  that  in  the  early  part  of 
the  disease,  when  the  index  was  high,  no  change  for  better  or  for  worse 
was  noted  following  vaccine,  but  later,  when  the  condition  was  poor  and 
the  opsonic  index  below  normal,  associated  with  a  rise  in  the  index  produced 
by  vaccine,  there  was  a  drop  in  temperature  and  definite  improvement. 

We  not  only  have  the  laboratory  evidence  of  the  efficiency  of  vac- 
cine in  producing  a  rise  in  the  opsonic  power  in  septicemia,  but  also 
evidence  of  associated  clinical  improvement,  which  renders  this  rise 
more  significant.  Purely  clinical  evidence  as  to  the  efficacy  of  vaccine 
in  septicemias  has  been  furnished  by  several  writers,  among  them 
Thompson.^ 

He  reports  7  cases  of  streptococcic  endocarditis  in  which,  following  the 
use  of  homologous  vaccine,  3  recovered;  in  2  of  the  fatal  cases  the  effect  of 
vaccine  was  strikingly  but  temporarily  beneficial,  and  in  2  other  cases  the 
benefit  was  sHght  but  demonstrable.  He  reports  i  case  of  advanced  pyemia 
as  cured.  In  all  cases  striking  effect  was  noted  in  the  decline  in  temperature 
following  vaccine,  and  there  was  associated  cUnical  improvement. 

Hartwell,  Streeter,  and  Green^  report  9.  septicemias  treated,  4  due  to  the 
staphylococcus  aureus,  5  to  streptococcus,  of  which  4  died.  Their  opinion 
was  that  in  those  that  recovered  successful  outcome  was  no  more  due  to  the 
vaccine  than  to  the  surgical  treatment.  In  18  cases  of  puerperal  sepsis,  15 
of  which  were  due  to  the  streptococcus,  they  state  that  the  effect  of  the  vaccine 
on  the  temperature  was  at  times  striking. 

Thompson's  method  of  treatment  consisted  of  fairly  large  and 
infrequent  dosage.  In  one  case  50,000,000,  100,000,000,  and  200,000,000, 
twice,  of  killed  streptococci,  were  given  at  six-day  intervals.  In  another 
10  inoculations  were  given,  varying  from  100,000,000  to  300,000,006,  at 
intervals  of  four  or  five  days.  In  another,  13,000,000  to  20,000,000 
were  given  on  account  of  the  feebleness  of  the  patient — 24  inoculations 
in  all — at  first  every  other  day  and  later  every  day. 

*  Trans.  Chicago  Path.  Soc,  December  i,  1908. 
^  Amer.  Jour.  Med.  .Sci.,  August,  1909. 
^  Surg.,  Gyn.,  and  Obst.,  September,  1909. 


698  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

The  ■tt-riter  has  treated  one  case  of  staphylococcus  septicemia  for  a  period 
of  three  weeks,  giving  from  25,000,000  to  100,000,000  every  day  at  first,  and 
later  every  other  day.  The  patient  recovered  several  months  after  inoculations 
were  stopped.  One  case  of  mahgnant  endocarditis  due  to  the  streptococcus: 
This  patient  was  in  a  critical  condition  when  seen ;  history  and  the  condition 
of  the  heart  indicated  an  endocarditis  of  long  standing.  Vaccine  was  given  in 
dosage  of  from  10,000,000  to  25,000,000  every  other  day.  There  were  abso- 
lutely no  untoward  results,  and  there  was  a  distinct  average  lowering  of  tem- 
perature. The  patient  died  of  cardiac  failure  after  about  two  weeks.  One 
case  of  pyemia  due  to  staphylococcus  was  apparently  temporarily  benefited  by 
vaccine,  but  finally  succumbed.  Six  cases  cf  septicemia,  following  localized 
infections,  some  of  them  of  joints,  were  treated  after  surgical  measures  had 
been  exhausted  and  bad  prognosis  had  been  given,  v-ith  ultimate  recovery  of  4. 

These  citations  suggest  that  vaccine  may  fulfil  a  distinct  indication 
in  generalized,  infections.  That  its  use  is  productive  of  a  rise  in  the 
opsonic  power  of  the  blood,  if  properly  given,  is  certain;  that,  associated 
with  this,  amelioration  in  symptoms  is  produced,  seems  apparent.  It  is 
entirely  too  much  to  expect  of  the  exhibition  of  vaccine  that  it  should 
be  a  cure-all  for  these  serious  cases.  There  are  unquestionably  many 
factors  to  be  considered  which  make  for  life  or  death  of  the  patient, 
and  over  w^hich  vaccine  can  have  no  control.  For  instance,  it  has  been 
clearly  shown  by  Rosenow  and  others  that  bacteria  have  the  po\A'er 
of  immunizing  themselves  agamst  the  blood  fluid.  Further,  it  has 
been  shown  by  Rosenow  that  virulent  pneumococci  resist  phagocytosis. 
Even  though  the  antibacterial  power  of  the  blood  were  raised  to  a  very 
high  degree,  it  might  not  be  able  to  cope  with  such  conditions.  We 
hsixe  further  to  consider  the  effect  of  the  poison  upon  the  functions  of 
certain  organs  which  may  be  injured  beyond  repair,  and  which,  in  spite 
of  the  efficient  response  of  the  immunizing  mechanism  to  vaccine,  would, 
nevertheless,  lead  to  an  ultimately  fatal  outcome. 

Diagnosis. — It  is  not  within  the  scope  of  this  chapter  to  enter  into 
details  of  bacteriologic  diagnosis.  As  in  the  case  of  every  infection  of 
importance,  accurate  bacteriologic  diagnosis  should  be  made  for  record, 
this  being  of  particular  importance  when  specific  treatment  by  vaccme 
may  be  required. 

When  possible  to  obtain  a  discharge,  diagnosis  may  be  readily  made, 
otherwise  blood-culture  will  be  necessary.  The  observation  of  Rosenow 
(loc.  cit.)  that  the  use  of  agar  as  a  medium  for  blood-cultures  yielded 
positive  growth  repeatedly  where  cultures  in  broth  remained  sterile, 
indicates  that  the  accepted  idea  that  fluid  media  are  always  preferable 
to  solid  media  for  blood-cultures  is  erroneous.      The  use  of  both  solid 


DOSAGE    IN    GENERALIZED    INFECTIONS  699 

and  liquid  media  will  not  only  tend  to  secure  greater  average  success, 
but  also  will  give  a  fair  idea  of  the  relative  numbers  of  bacteria  in  the 
blood. 

Dosagfe. — While  it  is  desirable,  if  possible,  to  guide  the  dosage  by 
means  of  the  opsonic  index,  it  is  possible  to  treat  this  type  of  case  de- 
pending upon  clinical  symptoms  alone.  It  should  be  borne  in  mind 
that  we  must  avoid  the  lowering  of  the  patient's  resistance  by  using 
excessive  dosage.  While  the  opsonic  po^ver  may  be  continuously  low, 
and  apparently  it  would  seem  that  even  large  doses  of  \'accine  could 
not  further  lower  it,  theoretically  we  should  expect  large  dosage  to 
do  nothing  else  than  to  increase  the  condition  of  overexcitation  under 
which  the  protective  mechanism  is  struggling.  Clinically,  we  find  that 
sometimes  even  small  dosage  will  be  followed  by  alarming  symptoms 
and  evidence  of  increased  toxemia.  This  would  not  appear  to  be  due 
to  the  amount  of  toxin  administered,  but  to  the  effect  it  has  upon  the 
protective  mechanism.  It  does  not  seem  that  this  toxic  effect  is  always 
registered  by  the  lowering  of  the  opsonic  power,  because  it  is  already 
much  reduced  perhaps,  but,  nevertheless,  clinical  experience  would 
indicate  that  we  have  in  some  manner  broken  down  the  barriers  of 
resistance  which  the  patient  normally  possesses.  We  should  not,  even 
after  a  few  hours,  allow  this  to  take  place.  We  can,  by  the  exhibition 
of  minute  doses  at  short  intervals,  achieve  a  slight  and  repeated  rise, 
in  the  opsonic  power,  and,  associated  with  this,  we  can  see  improvement 
without  any  injurious  effect  upon  the  patient.  Until  it  can  be  definitely 
shown  that  large  doses  can  be  given  without  harm,  we  must  in  practice 
hold  to  such  amounts  of  vaccine  as  will  he  effective  and  without  danger. 

In  the  case  of  streptococcus,  from  1,000,000  to  5,000,000  may  be  an 
initial  dose.  Two  millions  is  practically  always  safe.  This  should 
be  repeated  in  from  twelve  to  t\venty-four  hours,  and,  if  there  are  no 
untoward  effects,  may  be  increased  on  the  following  day.  Inasmuch 
as  the  dosage  depends  upon  the  virulence  of  the  vaccine  and  the  condition 
of  the  patient,  no  absolute  rule  can  be  given.  It  may  be  possible  to 
repeat  these  minute  doses  every  six  or  eight  hours  with  nothing  but 
benefit.  A  maximum  dosage  might  be  said  to  be  25,000,000  daily, 
though  this  will  not  always  apply.  Where  the  blood  infection  emanates 
from  a  local  focus,  the  increase  in  dosage  may  be  rapid  and  the  amount 
given  finally  larger.  As  the  dosage  is  increased  and  the  patient  improves, 
one-  or  two-day  intervals  between  the  doses  may  be  desirable.  In  the 
case  of  pneumococcus  the  dosage  is  practically  the  sam.e.  In  the  case 
of  staphylococcus  it  is  sometimes  found  that  the  organism  is  of  low 
virulence,  and  it  may  be  found  tha.t  even  from  100,000,000  to  200,000,000 


700  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THEBAPY 

may  be  given  every  two  or  three  days.  Much  care  must  be  taken  in 
giving  initial  doses  of  colon  vaccine,  the  dosage  being  from  5,000,000. 
The  virulence  of  all  vaccine  varies,  and  is  not  to  he  measured  hy  the  number 
of  bacteria  in  the  dose  given.  In  one  instance  an  inoculum  of  5,000,000 
streptococci  of  one  strain  might  conceivably  have  the  \irulence  of  five 
times  or  more  that  dose  in  the  case  of  another  strain.  The  dosage 
should  always  be  increased  in  such  a  manner  that  no  exacerbation  will 
be  produced.  The  sicker  the  patieM,  the  smaller  the  dose  that  should  be 
given. 

A  sudden  rise  in  temperature  and  increase  in  toxic  symptoms  suggest 
that  the  dosage  may  ha\'e  been  too  large.  These  signs  may,  however, 
have  been  produced  in  the  normal  course  of  events  and  have  no  relation 
to  the  vaccine.  If  the  dose  that  has  been  followed  by  such  signs  is 
minute,  there  is  no  contraindication  to  repetition  on  the  next  day.  If 
the  dose  was  of  larger  proportions,  it  would  be  well  to  reduce  its  size  next 
day. 

While  in  the  case  of  pneumococcus,  streptococcus,  and  staphylococcus, 
the  most  common  causes  of  the  septicemias,  immunity  appears  to  be 
largely  due  to  the  opsonin  and  the  phagocytes,  in  the  case  of  colon  and 
typhoid  we  see  in  the  agglutinins,  bactericidins,  etc.,  additional  factors 
of  equal  or  greater  importance.  The  development  of  these  substances 
is  by  no  means  parallel  to  that  of  opsonin,  but  in  the  case  of  a  given 
dose  of  vaccine,  these  substances  make  their  appearance  usually  later 
than  the  increase  in  opsonins.  Hence,  we  may  have  an  elevated  opsonic 
index,  and  at  the  same  time  a  low  agglutinating  power  in  these  infections. 
A  dose  of  suflScient  size  to  cause  a  decided  increase  in  opsonin  may  be 
inefficient  in  producing  agglutinins  in  large  amount.  It  is  desirable,  of 
course,  to  induce  formation  of  these  substances,  and  hence  in  colon 
infections  a  more  rapid  increase  in  dosage  is  ad\isable.  At  the  very 
start,  however,  dosage  must  be  small,  in  order  not  temporarily  to  lower 
the  opsonic  resistance.  Later,  it  would  appear  that,  at  least  clinically, 
within  certain  limits,  these  other  antibodies  more  than  balance  tempor- 
ary lowering  of  the  opsonic  index  after  good-sized  dosage.  In'  the  case 
of  a  child  with  colon  septicemia  following  appendectomy  the  writer 
gave  as  an  initial  dose  10,000,000,  on  the  following  day  20,000,000,  two 
days  later  40,000,000,  and  again,  two  days  after,  80,000,000,  with  im- 
mediate fall  in  temperature  and  recovery. 

INFECTIOUS   ARTHRITIS 

Suppurative  conditions  are  most  frequently  due  to  the  strep- 
tococcus, staphylococcus,  or  pneumococcus,  but  in  the  case   of   trau- 


INFECTIOUS    ARTHRITIS  7OI 

matic  infections  following  punctured  wounds,  other  organisms  may  be 
found.  After  thorough  drainage  by  surgical  measures,  the  most  im- 
portant indication  is  to  render  drainage  permanently  efEective.  The 
inefficiency  of  gauze  wicks  to  allow  of  good  drainage  has  been  considered. 
Their  action  is  commonly  more  effective  in  preventing  efficient  discharge 
than  in  promoting  it.  Where  mechanical  conditions  are  such  that  the 
operative  wound  naturally  closes  itself,  the  insertion  of  a  rubber  dam 
is  effective  in  preventing  this  closure.  The  uselessness  of  antiseptics 
as  irrigations  of  joints,  and,  in  fact,  their  positive  harm,  needs  little 
comment. 

The  prime  indication  in  these  infections,  as  well  as  in  all  others,  is 
to  produce  a  free  and  continuous  streaming  of  lymph  from  the  blood 
into  the  infected  focus,  in  order  that,  as  nearly  as  possible,  the  sum  total 
of  its  antibacterial  power  can  be  exerted  against  the  bacteria  as  they 
cultivate  themselves  in  the  tissues.  In  order  that  this  shall  take  place, 
evacuation  of  the  pus  and  elimination  of  pressure  is  the  first  necessity; 
the  second  is  to  perpetuate  a  free  and  clear  external  opening. 

The  usefulness  of  the  sodium  citrate  and  chlorid  solution  in  m^eeting 
these  requirements  has  been  sufficiently  considered.  In  practice  it  is 
possible,  by  use  of  this  solution,  to  prevent  any  tendency  to  crust  forma- 
tion, to  produce  a  discharge  as  long  as  is  desirable,  and  to  maintain  an 
unobstructed  opening  for  as  long  a  period  as  desired,  subject,  of  course, 
to  the  gradual  closure  that  w^ill  take  place  through  the  process  of  healing. 
It  appears,  in  general,  that  operative  wounds  heal  less  rapidly  if  this 
solution  is  kept  constantly  applied.  With  the  exception  of  the  definite 
indication  for  rubber  dam,  as  referred  to,  the  use  of  this  solution  fulfils 
every  requirement  for  the  maintenance  of  free  drainage.  This  renders 
possible  the  efficient  application  of  the  protective  substances  of  the  blood- 
serum  against  the  bacteria  in  the  focus  of  infection  in  a  more  continuously 
free  and  unobstructed  manner  than  would  otherwise  be  possible. 

When,  in  spite  of  these  measures,  the  infection  becomes  indolent, 
either  with  or  without  temperature,  the  use  of  appropriate  vaccine  is 
indicated.  Where  there  is  a  temperature,  the  dose,  of  course,  should  be 
small,  and  under  all  conditions  considerably  smaller  than  in  most  other 
localized  infections. 

Vaccine,  always  in  association  with  the  other  measures  indicated, 
has,  in  the  writer's  hands,  appeared  to  be  efficient  in  a  number  of  cases 
of  suppurative  joint  infection.  Two  cases  should  be  cited  in  which, 
following  operation,  a  septicemic  condition  developed,  streptococci  were 
isolated  from  the  blood,  and  vaccine  given,  with  ultimate  recovery  and 
good  functionating  joint. 


702  THERAPEUTIC  IMMUNIZATION   AND    VACCINE   THERAPY 

It  has  been  usually  the  case,  where  temperature  has  again  developed 
after  once  having  reached  normal,  that  some  pocket  of  pus  has  developed. 
Vaccine  cannot,  of  course,  be  expected  to  cope  with  such  a  complication, 
and  is  contraindicated  until  it  is  clear  that  foci  of  pus  are  satisfactorily 
evacuated. 

Gonorrheal  Arthritis. — These  infections  in  their  acute  stage 
present  a  condition  of  more  or  less  continuous  autoinoculation,  as 
evidenced  by  the  temperature.  The  ordinary  treatment  by  fixation 
of  the  part  affected  commonly  is  sufficient  to  satisfy  the  primary  indica- 
tion in  all  infections  associated  with  autoinoculation  and  temperature, 
namely,  the  elimination  of  such  autoinoculation  and  thus  the  production 
of  a  strictly  localized  infection. 

Inasmuch  as  in  the  ordinary  course  of  events  elimination  of  auto- 
inoculation is  secured  after  a  few  days  of  treatment,  it  does  not  appear 
necessary  to  use  vaccines  during  this  acute  stage. 

When  temperature  subsides  and  autoinoculation  consequently  ceases, 
we  usually  find  a  condition  of  lowered  opsonic  power  for  reasons  previ- 
ously discussed.  The  indication  is,  therefore,  to  furnish  a  stimulus,  by 
means  of  vaccine,  that  shall  set  in  motion  the  protective  mechanism  and 
result  in  the  elaboration  of  protective  substances  in  increased  amount. 

Although  certain  cases  of  gonorrheal  arthritis  gradually  progress 
toward  complete  recovery,  the  frequency  with  which  they  become  chronic 
and  resist  all  the  ordinary  measures  of  treatment  attests  the  failure  of  the 
immunizing  mechanism  in  these  cases. 

We  see  in  the  low  antibacterial  content  of  the  blood-stream,  and  the 
obstruction  to  circulation  produced  by  the  local  swelling,  factors  which 
render  this  chronicity  possible. 

The  consensus  of  opinion  among  those  who  have  treated  a  con- 
siderable number  of  cases  of  this  type  by  injections  of  gonococcic  vac- 
cine appears  to  be  that  vaccine  is  a  valuable  therapeutic  measure. 

Hartweir  reports  the  treatment  of  31  cases  of  gonorrheal  arthritis.  These 
cases  were  first  treated  at  periods  varying  from  one  month  to  one  year  after 
the  acute  attack.  In  27  of  these  cases  the  end-results  were  completely  func- 
tionating joints  without  disabifity.  Those  which  did  not  entirely  clear  up, 
so  far  as  function  is  concerned,  had  already,  when  treatment  was  started, 
become  ankylosed.  Dosage,  in  Hartwell's  chronic  cases,  reached  as  high  as 
500,000,000  to  600,000,000.  Interval  between  dosage  was  from  five  days  to 
a  week.  Subjective  symptoms,  such  as  malaise,  nausea,  and  vomiting,  were 
occasionally  produced,  but  no  untoward  event  occurred  which  was  ultimately 
serious.     He  prepared  his  vaccine  by  two  methods — the  first  exposure  to  60° 

^  Ann.  Surg.,  November,  1909,  p.  939. 


GONORRHEAL   ARTHRITIS  703 

C,  and  in  the  second  he  exposed  his  vaccine  in  an  ice-box  over  night,  added 
I  of  I  per  cent,  of  lysol,  and  allowed  it  to  stand  twelve  hours  before  using. 
There  appeared  to  be  no  differences  in  the  vaccinating  qualities  of  these  dif- 
ferently prepared  vaccines.  He  used  autogenous  vaccine  in  21  cases,  with 
what  he  considers  better  results  than  where  stock  vaccine  was  used.  His 
method  was  gradually  to  increase  the  dosage,  with  the  idea  of  overcoming 
tolerance  already  produced  by  previous  dosage. 

In  20  acute  cases  treated  he  thought  the  vaccine  diminished  pain  and 
hastened  resolution.  Nine  of  these  cases  recovered  with  free  motion  of  the 
joint  affected.  He  found  that  in  the  acute  cases  other  joints  became  in- 
fected after  the  first  few  inoculations.  He  thinks  these  were  due  to  the  or- 
dinary course  of  the  disease,  and  not  to  the  effect  of  the  vaccine.  His  dosage 
in  acute  cases  was  from  25,000,000  to  100,000,000,  and  the  interval  two  to 
four  days. 

Hartwell  concludes  that  gonococcal  vaccine  is  a  valuable  therapeutic 
agent  in  gonorrheal  arthritis  in  all  stages  except  where  ankylosis  has 
occurred.  It  does  not  prevent  extension  to  other  joints,  nor  does  it  pro- 
duce lasting  immunity  sufficient  to  prevent  recurrence  after  a  new  attack 
of  acute  urethritis. 

Thirty-one  cases  of  gonococcal  arthritis  were  treated  by  means  of  vaccine 
by  Irons.^  His  conclusions  are  conservative  when  he  states  that  in  certain 
cases  of  gonococcal  arthritis  recovery  can  be  hastened  by  injection  of  dead 
gonococci,  and  that  the  chronic  ambulator}'-  cases  showed  better  response  to 
inoculation  than  the  more  acute  cases.  Improvement,  however,  in  the  acute 
cases  often  seems  more  rapid  after  inoculation  than  by  other  treatment.  In 
15  cases  he  found  that  the  opsonic  index  was  low  at  first.  His  guidance  in 
the  use  of  vaccine  was  by  clinical  symptoms,  and  the  vaccine  used  was  of 
various  kinds,  varying  from  one  to  a  number  of  combined  strains. 

The  dosage  employed  by  him  at  first  was  20,000,000  to  50,000,000,  and 
later,  and  in  other  cases,  the  dosage  was  increased  to  100,000,000  and  rarely 
to  1,000,000,000,  with  an  interval  of  three  to  seven  days.  No  harm  was  done 
by  using  these  large  doses,  beyond  production  of  clinical  symptoms  during 
the  next  twenty-four  hours,  associated  with  the  negative  phase,  such  as  joint 
pain,  tenderness,  fever,  and  malaise  when  large  doses  were  given. 

Cole  and  Meakins^  report  the  treatment  of  15  cases.  They  used,  the 
opsonic  index  as  a  guide  for  treatment  and  found  that  in  each  case  inocula- 
tions were  followed  by  a  rise  in  the  opsonic  index  during  the  first  week;  that 
by  the  tenth  day  the  index  fell  again;  their  dosage  was  large,  varying  fr.^m 
200,000,000  to  1,000,000,000.  They  state  that  constitutional  disturbance 
was  met  with  rarely  and  was  severe  in  but  one  case.     They  re])eated  their 

^  Arch.  Int.  Med.,  i,  No.  4,  433. 

^  Bull.  Johns  Hopkins  Hospital,  June,  July,  1907,  p.  223. 


704     '        THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

inoculations  every  seven  to  ten  days.  They  conclude  that  the  chronic  cases 
show  better  results  than  the  acute.  Cases  that  have  progressed  slowly  under 
other  treatment  show  almost  immediate  improvement  soon  after  vaccine  is 
given. 

Considerable  numbers  of  cases  have  been  reported  by  other  observers, 
with  approximately  the  same  conclusions.  The  writer  has  had,  or  has 
at  present  under  treatment,  20  cases  of  chronic  gonorrheal  arthritis. 
In  16  treatment  was  begun  at  from  one  month  to  two  years  after  the 
acute  attack.  x\ll  these  cases  had  resisted  other  forms  of  treatment. 
Twelve  of  these  cases  recovered  completely  after  from  one  to  four  months' 
treatment,  with  complete  functionating  joints.  In  all  cases  stock  vaccine 
was  used.  The  initial  dosage  was  always  small — from  5,000,000  to 
10,000,000,  injected  at  intervals  of  three  to  five  days. 

The  attempt  was  made,  as  in  the  treatment  of  all  other  infections, 
to  so  gradually  increase  the  dose  that  the  general  symptoms  should  be 
entirely  avoided  and  focal  symptoms  so  far  as  possible.  In  no  case 
were  generalized  symptoms  produced.  In  chronic  cases  the  dosage  has 
rarely  exceeded  50,000,000.  In  4  acute  cases  treated  the  dosage  has 
been  from  5,000,000  to  25,000,000.  The  longest  period  of  treatment 
in  acute  cases  was  two  months.  There  was  no  fresh  joint  involvement 
after  the  treatment  had  begun.  In  these  cases  the  inoculations  appeared 
to  have  some  control  over  the  pain. 

One  case,  which  is  particularly  striking,  is  that  of  a  man  twenty-five 
years  old,  who  had  several  joints  affected  for  over  two  years.  The  con- 
dition remained  more  or  less  active  in  the  ankles,  and  there  w^as  con- 
siderable tenderness  and  swelling  in  the  plantar  surfaces  of  the  feet. 
Walking  was  extremely  painful,  and  the  patient  had  been  unable  to 
go  about  his  work  for  a  long  time.  An  inoculation  of  5,000,000  was 
given,  and  five  days  later  10,000,000.  Two  days  after  the  first  dose  the 
patient  stated  that  he  could  walk  with  less  pain,  and  after  the  second 
dose  he  walked  into  the  clinic  without  any  perceptible  lim.p.  In  this 
case  there  was  complete  recovery  after  eight  inoculations. 

So  far  as  is  known  there  has  been  no  recurrence.  Treatment  has 
been  started  on  a  number  of  cases  with  such  immediately  beneficial 
results  that  the  patients  have  ceased  attending  the  clinic,  and,  therefore, 
the  outcome  is  unknown. 

Diagnosis. — In  the  absence  of  definite  evidence  on  which  to  base 
a  diagnosis,  one  may  give  vaccine  as  a  therapeutic  test.  It  is  more 
satisfactory,  however,  to  arrive  at  a  diagnosis,  and  this  may  commonly 
be  achieved  by  the  use  of  a  method  offered  by  Irons.^     He  found  that 

^  Arch.  Int.  Med.,  190S,  i,  p.  432. 


GONORRHEAL   ARTHRITIS  705 

the  injection  of  500,000,000  of  dead  gonococci  into  an  individual  not 
suffering  from  gonorrheal  infection  would  produce  no  constitutional  or 
■*  other  disturbance,  while  in  an  infected  individual,  after  such  an  inocula- 
tion and  during  the  subsequent  twenty-four  hours,  there  vv'ould  occur  a 
negative  opsonic  phase,  and  associated  with  it  would  be  increased  pain 
and  tenderness  in  the  joints,  general  feeling  of  malaise,  and  fever.  In 
a  doubtful  case  the  use  of  this  method  of  diagnosis  is  advantageous. 
Its  only  disadvantage  is  the  production  of  unpleasant  symptoms.  Per- 
manent harm,  it  appears,  has  in  no  case  occurred. 

The  use  of  opsonic  index  in  the  diagnosis  of  joint  infections  is  a  very 
accurate  method  if  technique  of  opsonic  index  determinations  is  thor- 
oughly mastered.  This  applies  not  only  in  the  diagnosis  of  gonococcus 
joints,  but  also  in  any  problem  of  differential  diagnosis  relating  to  joint 
infections.  If  the  question  is  between  tuberculous  and  gonococcus 
infection,  a  series  of  indices  from  day  to  day,  determined  against  the 
gonococcus  and  the  tubercle  bacillus  respectively,  may  furnish  the  evi- 
dence sought.  If  the  indices  to  the  tubercle  bacillus  are  within  the  normal 
limits,  and  those  to  gonococcus  are  continuously  subnormal  or  show 
marked  and  wide  variations  from  day  to  day,  we  may  reasonably  make 
a  diagnosis  of  gonococcus  infection.  If  the  indices  to  tubercle  bacillus 
show  a  subnormal  condition  or  wide  variations  from  day  to  day,  and  the 
gonococcus  indices  are  practically  within  the  normal  limits,  we  must 
deduce  that  we  are  dealing  with  a  tuberculous  infection.  Diagnosis 
cannot  be  made  by  means  of  one  opsonic  index  determination,  and  it 
is  always  well  to  obtain  two  or  more  on  different  days  where  diagnosis 
is  important. 

Diagnosis  by  means  of  opsonic  index  variation  after  induced  auto- 
inoculation  is  one  of  the  most  delicate  and  accurate  means  of  serum 
diagnosis  which  can  be  used.  This  depends  upon  the  fact  that  if  an 
infected  focus  is  stirred  up  by  manipulation,  there  follow  the  same 
fluctuations  in  the  opsonic  index  that  an  injection  of  dead  organisms 
of  the  same  type  would  produce.  The  observation  of  Freeman,  as  re- 
ferred to  by  Wright,^  has  been  noted  before.  He  showed  that  following 
massage  of  a  gonococcal  joint  decided  elevations  of  the  opsonic  index 
took  place;  that  following  the  massage  there  was  a  temporary  aggrava- 
tion in  the  joint  troubles,  which  suggested  the  induction  of  a  negative 
phase ;  that  in  association  with  elevation  of  the  opsonic  power,  not  only 
the  joints  which  were  massaged  improved,  but  also  other  affected  joints; 
that  like  variations  in  the  opsonic  power  may  be  produced  by  other 
measures  than  massage  {loc.  cit.,  Wright's  chart  39),  for  instance,  by 
^Lancet,  November  2,  1907,  1226. 
45 


7o6 


THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 


passive  hyperemia  produced  by  Bier's  bandage.  There  can  be  no  other 
reasonable  explanation  for  this  phenomenon,  except  that  of  Freeman, 
who  saw  in  the  fluctuations  of  the  opsonic  index,  following  manipulations 


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of  the  focus  of  infection,  a  register  of  immunizing  response  to  bacteria 
and  their  toxin  thus  sent  into  the  blood. 

The  method  of  diagnosis  may  be  as  follows:   In  the  case  of  a  joint 
in  an  extremity  Bier's  bandage  should  be  applied  for  one-half  hour,  and 


INFECTIOUS   ARTHRITIS  707 

opsonic  determinations  made  in  the  specimens  of  blood  taken  from  the 
patient  before  bandage,  immediately  after,  and  one  hour,  two  hours, 
four  hours  after,  and  twice  on  the  following  day.  If  the  joint  is  infected 
by  gonococcus,  we  should  have  wide  variations  in  the  opsonic  indices, 
which  would  be  due  to  the  immunizing  response  of  the  organism  to  the 
bacteria  and  their  products  sent  into  the  circulation  by  the  hyperemic 
condition  of  the  joint.  If  the  diagnosis  lies  bet\veen  gonococcus  and 
tuberculous  joint,  the  same  specimens  of  blood  should  be  tested  against 
tubercle  bacillus.  The  absence  of  variations  of  the  tubercular  opsonic 
index,  and  the  presence  of  wide  variations  in  the  gono- opsonic  index,  or 
vice  versa,  would  prove  the  nature  of  the  infection.     (See  Fig.  262.) 

This  same  method  of  diagnosis  may  be  applied  to  differentiate  gono- 
coccus from  other  joint  infections,  such  as  pneumococcus  or  strepto- 
coccus, in  the  same  maimer.  The  difficulty,  however,  of  obtaining 
accurate  opsonic  indices  will  limit  the  usefulness  of  this  method  of 
diagnosis. 

These  methods  are  so  valuable  that  they  should  not  be  neglected, 
but,  unfortunately,  the  labor  necessary  in  carrying  them  out  is  so  great, 
and  the  technique  is  so  time  consuming,  that  it  is  often  impossible  for 
those  experienced  in  opsonic  technique  to  make  use  of  them  to  any  great 
extent. 

Other  Types  of  Infectious  Arthritis.— There  are  certain  non- 
suppurative inflammiatory  processes  occurring  in  and  about  the  joints 
the  characteristics  of  which  are  decidedly  in  favor  of  their  being  of 
bacterial  origin.  Until  recently  many  acute  and  subacute  inflammatory 
conditions  of  the  joints  and  periarticular  tissues  have  been  grouped 
under  the  general  heading  of  rheum.atism.  Based  on  the  character  of  the 
disease,  the  t}^pical  so-called  ariiculav  rJieiimatism  has  been  for  some 
time  placed  in  the  group  of  bacterial  infections,  although  no  definite 
organism  has  as  yet  been  proved  conclusively  to  be  the  cause  of  this 
disease-.  There  are,  however,  beyond  the  typical  rheumatic  fever,  non- 
suppurative inflammatory  conditions  of  the  joints  which  are  associated 
with  similar  constitutional  and  local  symptoms  and  signs,  characteristics 
which  are  quite  as  much  in  favor  of  their  being  considered  infectious 
processes  as  the  same  are  in  favor  of  the  infectious  nature  of  acute  articu- 
lar rheumatism.  These  arthritic  conditions  very  commonly  follow 
apparently  localized  infections,  such  as  tonsillitis,  pharyngitis,  and 
rhinitis.  They  are  rather  common  sequelae  of  scarlet  fever.  The  fact 
that  these  conditions  often  follow  acute  local  infections  suggests  that  the 
infective  material  has  been  transferred  to  the  blood-stream  and  the 
bacteria  \\a,\t  lodged  and  grown  in  and  about  the  joint. 


7o8  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

It  would  appear,  as  has  been  previously  suggested,  that  local  in- 
fections associated  with  temperature  are  not  really  local,  but  are  more 
or  less  continuously  sending  bacteria  into  the  blood-stream.  Decidedly 
in  favor  of  this  is  the  fact  of  wide  fluctuation  in  the  opsonic  power  of  the 
blood,  which  can  be  due  to  nothing  else  than  the  taking  up  of  bacteria 
and  their  products  by  the  blood-stream. 

Sequence  of  events  in  scarlet  fever  often  furnishes  evidence  that 
bacteria  exist  in  the  circulating  blood,  derived  originally  from  the  throat 
infection  as  an  atrium.  In  severe  cases  streptococci  can  commonly 
be  obtained  by  blood  culture.  In  postscarlatinal  nephritis  they  are  to 
be  found  in  large  numbers  in  the  kidney.  In  the  writer's  observation 
of  scarlet-fever  cases  at  the  Boston  City  Hospital,  South  Department, 
during  a  period  of  over  two  years,  scarlatinal  arthritis  was  frequently 
seen.  It  was  of  all  degrees,  varying  from  slight  periarticular  inflamma- 
tion, associated  with  a  little  temperature,  to  a  condition  of  suppuration  in 
one  or  more  joints.  In  every  case  (6)  of  this  kind  that  came  to  opera- 
tion the  streptococcus  was  demonstrated  in  pure  culture  in  the  pus. 
It  would  seem  reasonable,  therefore,  to  attribute  these  arthritic  condi- 
tions in  scarlet  fever  to  streptococcus  infection,  varying  in  intensity 
according  to  the  protective  reaction  which  they  induce  in  the  patient. 
It  is  quite  as  reasonable  to  attribute  the  acute  arthritic  conditions  fol- 
lowing tonsillitis  to  entrance  of  bacteria  into  the  blood-stream  and 
localization  in  and  about  the  joint,  in  tissues  which  are  normally  poor 
in  vessels,  where  the  supply  of  protective  substances,  therefore,  must 
be  correspondingly  less  than  in  better  vascularized  tissue. 

The  bacteria,  having  been  transferred  into  the  blood-stream  and 
lodged  in  such  poorly  vascularized  tissues  as  those  about  the  joints, 
soon  render  the  local  conditions  more  suitable  for  their  growth.  They 
accomplish  this  by  abstraction  of  antibacterial  substances  from  the 
lymph  in  the  immediate  vicinity  of  the  locus,  and  through  swelling  and 
exudation  which  ensue  it  becomes  more  and  more  difficult  for  an  inter- 
change between  the  fluid  in  the  locus  and  fresh  lymph  from  the  blood- 
stream to  take  place.  The  bacteria,  then,  have  most  excellent  condi- 
tions for  growth  in  a  more  or  less  stagnant  fluid  of  continuously  low  anti- 
bacterial power.  The  blood-stream  has  been  able  to  ward  off  infection 
of  a  generalized  type,  but  the  fact  that  infection  has  taken  place  clearly 
indicates  that  it  has  not  been  able  to  exert  its  full  power  against  the 
bacteria  in  the  tissues. 

As  a  result  of  the  dcA^elopment  of  localized  infection,  the  blood- 
stream itself  suffers  in  a  decided  manner  a  loss  of  a  considerable  por- 
tion of  its  antibacterial  power.     The  opsonic  index  in  these  localized 


INFECTIOUS    ARTHRITIS 


709 


infections  is  consistently  subnormal.  A  reasonable  explanation  of  this 
fact  would  appear  to  be,  first,  that  the  blood  is  unable  to  derive  sufficient 
autoinoculation  to  induce  formation  of  protective  substances,  because  the 
localized  condition  shuts  it  off  from  anything  like  a  free  circulation, 
and  it  consequently  takes  up  but  few  bacteria;  secondly,  the  blood 
suffers  a  gradual  loss  of  opsonin  and  other  antibodies  which  it  would 
otherwise  have  by  continuous  slight  contact  with  the  outskirts  of  the 
bacterial  focus. 

We  can  justifiably  ascribe  the  chronicity  of  some  of  these  infections 
to  the  same  conditions  that  apply  to  all  chronic  infections;   namely,  a 
low  opsonic  power  of  the  blood-stream,  and  the  difficulty  of  its  coming 
into  contact  intimately  with  the  bacteria  in  the  focus  in  sufficient  amount 
to  cause  their  destruction.     We  need  no  better  confirmation  of  this 
than  the  sequence  of  events  which  follows  the  forced  entrance  of  fresh 
lymph  into  the  focus,  by  means  of  Bier's  bandage,  and  the  subsequent 
drainage  of  this  lymph  into  the  circulation.     Clinically,  such  procedure 
.  is  commonly  follo\ved  by  marked  amelioration  in  local  signs  and  symp- 
toms, not  only  in  the  joint  to  which  the  bandage  was  applied,  but  to 
other  infected  joints  if  there  be  any.     By  means  of  opsonic  determinations 
we  find  variations  quite  similar  to  those  produced  by  an  inoculation  of 
a  vaccine  derived  from  a  corresponding  organism.     First  there  may  be 
a  negative  phase  and  subsequently  a  positive  phase.     This  can  mean 
nothing  else  than  that  these  variations  register  an  immunizing  response, 
and  indicate  that  the  increased  supply  of  blood-fluid  has  abstracted 
from  the  focus  sufficient  bacteria  and  toxin  to  constitute  an  autoinoculat- 
ing  ictus,  thus  leading  to  the  increased  formation  of  antibacterial  sub- 
stances.    We  can  also  see,  as  a  reason  for  the  improvement  in  the  local 
focus,  the  replacement  of  the  stagnant  lymph  in  the  focus  of  infection 
by  fresh  lymph  from  the  blood  of  higher  antibacterial  power.     In  these 
considerations  we  can  derive  indications  for  treatment. 

The  question  of  using  Bier's  bandage  as  a  therapeutic  measure  has 
been  discussed.  Its  advantage  lies  in  the  fact  that  no  diagnosis  is 
necessary;  its  disadvantage,  in  the  fact  that  the  dosage  of  living  vaccine 
that  is  sent  into  the  body  cannot  be  measured,  and  always  there  is  the 
possible  danger  of  the  development  of  new  foci  in  other  parts  of  the 
body.  Unquestionably  the  response  to  a  living  vaccine  of  exactly  the 
infecting  organism  is  of  more  efficiency  than  that  following  the  use  of 
a  killed  corresponding  vaccine.  It  is  a  very  much  safer  procedure  to 
make  use  of  vaccine. 

The  question  of  bacteriologic  diagnosis  is  the  most  important  and 
the  most  difficult  one  to  settle.     The  difficulty  of  obtaining  a  positive 


7IO  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

blood-culture,  even  in  some  cases  of  septicemia,  indicates  that  in  these 
cases  positive  results  from  blood-culture  are  not  to  be  expected,  except 
possibly  in  cases  where  there  is  temperature. 

Bearing  in  mind  the  possibility  that  the  condition  may  have  started 
from  a  localized  infection,  a  history  of  tonsillitis,  laryngitis,  or  pharyngi- 
tis should  be  sought,  and  cultures  taken  from  the  tonsils  or  nasopharynx 
or  nasal  cavity,  as  may  be  suggested  by  the  history  or  by  the  local  con- 
ditions. If  the  cultures  obtained  in  this  way  are  suggestive,  as,  for 
instance,  a  pure  culture  of  pneumococcus  or  streptococcus  would  be, 
the  next  procedure  is  to  determine  the  opsonic  index  against  this  particu- 
lar organism.  If  on  several  successive  days  the  opsonic  index  is  low,  or 
if  it  shows  wide  fluctuation,  say,  between  0.75  and  1.30,  and  if,  when  the 
same  specimens  of  blood  are  tested  against  some  other  organism,  the 
opsonic  indices  are  normal,  we  hav^e  conclusive  e\idence  that  we  have 
found  the  infecting  organism. 

A  second  and  better  method  is  to  apply  Bier's  bandage  for  diagnosis, 
as  described  in  the  section  on  Gonorrheal  Joints.  Variations  in  the 
opsonic  index  to  any  particular  organism  register  immunizing  response, 
and  indicate  clearly  that  autoinoculation  of  a  corresponding  organism 
has  been  induced  by  the  passive  hyperemia. 

These  methods  are  not  commonly  at  the  disposal  of  the  practitioner, 
and  hence  they  will  not  be  used  except  by  those  who  have  facilities  for 
turning  out  accurate  opsonic  indices.  It  would  appear  to  be  justifiable 
in  the  case  of  pure  culture  of  pneumococcus,  for  instance,  obtained 
from  the  tonsils,  to  prepare  an  autogenous  vaccine  and  make  use  of  it 
as  a  therapeutic  test.  In  febrile  cases  dosage  should  run  from  5,000,000 
to  25,000,000;  in  afebrile  cases  from  10,000,000  to  100,000,000  or  more. 
Where  the  dose  is  small,  the  interval  should  be  short.  As  the  dose  is 
increased  in  the  chronic  cases,  three  days  to  a  week  may  elapse  between 
the  doses.     The  initial  dose  is  always  the  minimal. 

Before  vaccine  is  given,  the  first  indication  is  the  elimination  of  auto- 
inoculation by  fixation  of  the  joint,  or,  in  case  several  are  affected, 
absolute  rest  will  be  advisable  to  accomplish  this  end. 

There  have  been  rejDorted  but  a  few  cases  of  treatment  by  vaccines 
of  these  non-suppurati\'e  joint  conditions.  Two  interesting  cases  of 
this  type  have  been  seen  by  the  v/riter,  and  one  of  them  was  successfully 
treated. 

Case  I. — The  patient,  a  woman  of  fort}'-five  years,  suflFered  with  so-called 
rheumatism  for  a  period  of  ten  years.  She  was  referred  to  the  writer  to  settle 
the  question  of  diagnosis  and  treatment.     During  this  time  different  joints 


INFECTIOUS   ARTHRITIS  7II 

became  successively  involved,  and  each  attack  was  associated  with  some 
fever,  malaise,  pain,  tenderness,  and  swelling  about  the  infected  joint.  After 
two  or  three  weeks  the  condition  would  begin  to  quiet  down,  leaving  stiffness, 
slight  swelling,  and  some  disabiUty.  Rarely  were  two  joints  affected  at  the 
same  time.  The  knees,  the  ankles,  the  elbows,  and  shoulders  have  been 
successively  involved.  The  general  condition  of  the  patient  was  very  good, 
and  there  has  been  no  special  loss  of  weight.  She  had  been  subject  to  attacks 
of  tonsillitis,  although  the  throat  showed  nothing  but  moderately  enlarged 
tonsils.  The  question  of  the  tonsils  being  the  atrium  of  infection  was,  of  course, 
immediately  considered,  and  cultures  were  planted  on  acetic  agar.  A  pure 
growth  of  pneumococcus  was  obtained. 

It  was  impossible  at  the  time  to  prove  by  opsonic  indices  whether  this 
pneumococcus  was  the  actual  cause  of  the  arthritis,  but  it  was  thought  wise 
to  prepare  an  autogenous  vaccine  and  to  give  it  for  therapeutic  test.  After  a 
few  inoculations  of  from  5,000,000  to  25,000,000,  given  at  three-  to  five-day 
intervals,  the  most  marked  changes  took  place.  In  the  recently  involved  joint 
the  process  quieted  down  almost  immediately,  and  in  the  joints  that  had  been 
affected  for  some  time  there  was  immediate  and  progressive  improvement. 
The  patient  has  since  gone  on  to  practically  complete  recovery,  with  very  little 
disabilit}',  and  in  eight  months  has  had  no  recurrence. 

The  following  case  was  not  treated  by  vaccine.  It  is  recorded  be- 
cause it  is  suggestive  of  a  condition  of  joint  infection  dependent  on  a 
local  process  as  an  atrium,  and  is  a  type  of  case  several  of  which  the 
v^riter  has  seen  in  the  past  ten  years,  in  young  persons.  All  of  them 
recovered  completely  after  a  few  weeks,  with  no  immediate  recurrence. 


Case  II. — Patient  for  a  week  had  suffered  from  a  very  acute  rhinitis,  as- 
sociated with  profuse  discharge,  temperature  oftentimes  reaching  102°,  con- 
siderable malaise,  and  prostration.  Streptococcus  in  long  chains  was  found 
almost  pure  in  the  secretion  from  the  nose.  At  the  end  of  a  week  the  nasal 
condition  began  to  abate,  and  the  discharge  become  more  purulent.  At  this 
time  the  outer  aspect  of  the  left  knee-joint  developed  an  area  of  tenderness 
about  the  size  of  the  palm.  It  seemed  to  involve  the  tissues  about  the  inser- 
tion of  the  tendons.  Two  days  later  the  ball  of  the  right  foot  became  slightly 
tender  and  swollen.  Later  this  extended  to  the  heel,  and  still  later  involved 
the  plantar  surface  of  the  left  foot.  In  the  subsequent  two  weeks  the  first 
metacarpal  joint  of  the  left  little  finger  became  swollen;  a  tender  area  de- 
veloped over  the  head  of  the  left  radius  and  about  the  right  elbow.  There 
was  occasionally  a  temperature  of  a  degree  at  night.  The  patient  felt  at  the 
time  considerably  below  par,  but  was  able  to  walk  about  with  more  or  less 
pain.  After  three  weeks  the  conditions  l^egan  to  abate  in  all  the  joints,  and 
finally  practically  disappeared  after  about  six  weeks. 


712  THERAPEUTIC    IMMUNIZATION   AND    VACCINE   THERAPY 

This  case  is  given  because  it  suggests  tiie  probability  of  the  trans- 
ference, by  the  blood,  of  streptococci  which  found  suitable  locus  for  their 
growth  in  the  tissues  about  the  joint.  It  also  would  show  that  the 
body  is  able  to  immunize  itself  in  spite  of  the  fact  that  streptococci  have 
been  well  scattered  about  the  body.  It  suggests  that  the  blood-stream, 
as  has  been  noted  before,  resists  the  growth  of  bacteria  in  itself,  but  at 
the  same  time  may  not  be  able  to  destroy  them  before  they  have  found 
suitable  culture  grounds  for  their  growth. 

There  is,  theoretically,  no  class  of  cases  that  offer  any  clearer  indica- 
tion for  specific  treatment  by  bacterial  vaccine  than  infectious,  non- 
suppurative arthritis  or  periarthritic  infections  if  accurate  bacteriologic 
diagnosis  can  be  made. 

There  is  no  danger  in  the  use  of  bacterial  vaccine  if  dosage  is  so 
carefully  graded  that  no  symptoms  are  produced. 

There  is  always  a  positive  danger  of  over-autoinoculation  and  the 
possible  development  of  other  foci  if  Bier's  bandage  is  used.  Bier's 
bandage  furnishes  the  exact  requirement  in  the  way  of  supplying  vaccine 
to  stimulate  the  protective  mechanism;  it  also  provides  for  increased 
interchange  of  lymph  in  the  focus.  But  it  is  clear  that,  as  the  focus  of 
infection  begins  to  clear  up,  the  bacteria  become  fewer,  the  size  of  the 
autoinoculations  become  smaller  and  smaller,  and  hence  less  and  less 
effective  in  raising  the  antibacterial  power  of  the  blood.  In  other  words, 
when  large  dosage  of  vaccine  is  clearly  indicated,  the  dosage  obtained  in 
this  way  is  progressively  smaller  and  less  effective. 

LOCALIZED  STAPHYLOCOCCIC  INFECTIONS 
Furuncle. — When  the  patient  appears  for  the  first  time  with  a 
small  furuncle,  originating  perhaps  from  an  infected  hair-follicle,  which 
is  red,  painful,  and  tender,  to  a  degree  depending  on  the  location  and  the 
tenseness  of  the  tissue,  the  treatment  should  be  regulated  according  to 
the  stage  of  the  infective  process.  If  there  is  as  yet  no  evidence  of  lique- 
faction or  slough,  a  single  dose  of  100,000,000  Staphylococcus  pyogenes 
aureus  stock  vaccine  will  ordinarily  suffice  to  abort  it.  After  a  few 
hours  of  somewhat  increased  local  tenderness  and  swelling  a  marked 
improvement  in  the  appearance  and  symptoms  will  become  apparent, 
and  twenty-four  hours  later  the  tenderness  may  have  practically  disap- 
peared. An  inoculation  of  100,000,000  to  200,000,000  at  the  end  of 
forty-eight  hours,  followed  by  a  repetition  after  two  or  three  days,  may 
be  necessary,  but  these  two  or  three  moculations  will  generally  suffice. 
As  an  adjuvant  to  the  vaccine,  heat  may  be  applied  locally  by  means  of 
a  hot-water  bag.     It  is  applied  with  the  greatest  advantage  during  the 


LOCALIZED  STAPHYLOCOCCIC  INFECTIONS  713 

positive  phase  when  the  blood  is  at  its  best,  that  is  to  say,  six  or  eight 
hours  after  the  first  inoculation  or  more,  depending  on  the  size  of  the 
dose. 

If,  when  first  seen,  the  furuncle  shows  a  tendency  to  point,  and  lique- 
faction of  the  tissue  is  in  evidence,  a  minute  incision  should  be  made 
at  such  a  point  that  it  will  drain  readily.  This  should  be  more  in  the 
nature  of  a  puncture  than  an  incision.  The  pus  should  be  expressed, 
so  far  as  possible,  and  then  a  pad  of  gauze,  thoroughly  wet  in  Wright's 
solution  of  sodium  citrate  and  sodium  chlorid,  previously  described, 
should  be  applied  and  kept  wet  so  long  as  any  discharge  is  maintained. 
The  action  of  the  sodium  citrate  will  be,  of  course,  to  prevent  crusting, 
and  of  the  sodium  chlorid,  to  draw  fresh  serum  through  the  opening, 
thus  insuring  a  continuously  acting  free  drainage  and  a  consequent  free 
bathing  of  the  infected  focus  in  a  continuously  fresh  stream  of  serum 
from  the  circulating  blood.  We  have,  in  the  stream  of  fresh  anti- 
tryptic  serum,  the  best  agent  for  the  neutralization  of  the  tryptic  pus  and 
an  adjuvant  to  the  destruction  of  the  bacteria  by  the  leukocytes.  Wide 
incision,  such  as  might  break  through  the  walling-off  tissue,  is  in  these 
cases  bad,  because  it  opens  up  fresh  channels  for  the  extension  of  infec- 
tion. The  dosage  of  vaccine  under  these  conditions  should  be  as  given 
above.  On  the  second  day  the  drainage  will  ordinarily  be  found  to  be 
free  through  the  opening,  and  there  will  be  improvement  in  every  sign 
and  symptom.  The  application  of  heat  will  hasten  the  process  of 
separation  or  liquefaction  of  the  slough,  and  in  forty-eight  hours  the 
furuncle  should  be  well  discharged.  Subsequent  dosage  of  200,000,000 
after  two  days,  and  300,000,000  to  400,000,000  after  a  similar  or  slightly 
longer  period,  practically  always  effects  a  rapid  cure.  It  should  be 
remembered  that  in  all  cases  where  Wright's  citrate  and  salt  solution 
is  used,  the  skin  about  the  lesion  should  be  protected  at  every  dressing 
by  the  application  of  boric  ointment  in  order  to  prevent  pustulation, 
which  the  concentrated  salt  solution  commonly  induces. 

A  localized  abscess  of  larger  proportions  will  require  an  immediate 
and  adequate  incision,  which  should,  at  the  same  time,  be  as  small  as 
conditions  will  allow.  Sodium  citrate  and  salt  solution  should  be  applied 
as  a  dressing. 

In  all  cases  the  patient  should  be  given  a  cathartic,  preferably  calomel, 
followed  in  tweh^e  hours  by  a  Seidlitz  powder  if  the  bowels  are  at  all 
constipated. 

Furunculosis. — When  the  patient  gives  a  history  of  recurrence  of 
furuncles  over  a  longer  or  shorter  period,  the  problem  for  vaccine  be- 
comes more  complicated.     It  has  been  the   writer's  experience  that 


714  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

furunculosis  commonly  follows  any  change  in  diet  or  in  mode  of  life, 
such  as  would  be  consequent  to  a  railroad  journey,  to  a  camping  trip, 
or  residence  in  summer  hotels.  Overwork,  overstudy,  and  over- 
exercise  as  weU  seem  to  predispose  to  furunculosis.  Skin  of  a  certain 
type  is  often  associated  with  a  tendency  to^^-ard  infection  by  pyogenic 
cocci.  Such  a  skin  is  apt  to  be  oily  and  pale,  indicating  poor  circula- 
tion, and  subject  to  comedones. 

Every  practitioner  of  medicine  has  had  impressed  upon  him  by 
experience  the  difficulty  in  the  cure  of  these  cases  by  ordinary  methods. 
No  sooner  will  one  furuncle  be  incised  and  begin  to  heal  than  others 
develop.  A  repetition  of  surgical  operation  is  associated  with  a  repetition 
of  furuncle.  The  patient  complains  often  of  headache,  of  being  easily 
excited,  of  indefinite  pains  and  exhaustion,  m.alaise,  or  poor  appetite, 
besides  the  irritation  and  pain  consequent  to  the  furuncles,  repeated 
operative  procedures,  and  the  inconvenience  of  the  constant  application 
of  dressings  to  the  different  parts  of  the  body.  There  is  no  class  of 
cases  that  is  more  satisfactory  in  the  results  achieved  by  vaccine  therapy, 
and  none  in  which  the  patient  is  himself  better  convinced  of  the  efficacy 
of  such  measures. 

It  is  always  best  in  cases  of  this  chronic  type  to  isolate  from  the  pus 
the  particular  organism  that  is  causing  the  trouble,  and  to  prepare  a 
vaccine  at  once.  In  the  majority  of  cases  stock  vaccine,  composed  of 
three  or  four  virulent  strains  of  staphylococcus  aureus,  will  be  satisfactory, 
and  should  always  be  used  until  an  autogenous  vaccine  can  be  prepared. 
Better  results  will  be  obtained  in  the  long  run  by  using  the  vaccine 
prepared  from  the  particular  infecting  organism.  The  first  dose  should 
be  100,000,000  to  150,000,000.  It  should  be  repeated  on  the  third  day, 
increased  to  perhaps  200,000,000,  and  four  days  later  about  300,000,000 
should  be  administered.  After  a  few  trials  one  will  be  able  to  judge 
efficiently  as  to  the  size  of  dose  that  is  best  borne.  The  following 
clinical  data  will  be  of  assistance. 

If,  on  the  day  following  inoculation,  the  present  furuncles  become 
more  inflamed  and  one  or  two  new  furuncles  develop,  and  there  is  some 
general  malaise,  it  is  probable  that  a  smaller  dose  will  be  more  advantage- 
ous. If,  however,  on  the  day  following  inoculation  there  is  a  slight 
exacerbation,  but  on  the  next  day  marked  improvement  is  evident  in 
the  patient's  general  condition,  and  no  new  furuncles  put  in  their  appear- 
ance, and  if  this  improvement  is  maintained  for  two  or  three  days  longer, 
the  proper  dose  has  been  arrived  at.  This  dose  can  be  repeated,  and 
may  be  slightly  increased,  four  or  five  days  after  the  first  injection. 
New  furuncles  may  continue  to  come  at  intervals  for  some  weeks,  but 


FURUNCULOSIS;    DURATION   OF   IMMUNITY  715 

they  will  be  less  acute,  they  will  disappear  more  quickly,  and  will  give 
much  less  trouble  than  the  original  crop. 

Duration  of  treatment  depends  on  the  previous  chronicity  of  the 
case  and  on  the  location  of  the  furuncles.  If  they  are  situated  chiefly 
on  the  back  of  the  neck  and  many  comedones  are  present,  the  outlook 
for  immediate  cure  is  not  good.  The  writer  has  treated  several  cases  of 
this  kind  for  three  or  four  months  before  the  neck  has  entirely  healed 
up.  If  the  furuncles  are  scattered  over  the  body,  they  will  be  found 
to  be  much  more  rapidly  amenable  to  treatment  than  if  localized  on  the 
neck. 

Duration  of  Immunity. — Where  treatment  is  being  applied  for  the 
cure  of  a  single  boil  or  furuncle,  and  there  is  no  history  of  previous  at- 
tacks, usually  there  will  be  no  recurrence  within  some  months.  In  cases 
of  recurrent  furuncle,  after  a  sufficiently  prolonged  course  of  treatment, 
it  has  been  the  writer's  experience  that,  as  a  rule,  there  is  no  recurrence 
within  at  least  six  months  following  the  cessation  of  treatment. 

In  chronic  furunculosis  of  the  back  of  the  neck,  with  a  duration, 
as  often  happens,  of  months  or  years,  there  will  persist  a  chronic  indur- 
ated condition  of  the  tissues,  often  of  considerable  depth,  and  one  or 
more  small  discharging  sinuses.  The  prognosis  after  treatment  with 
autogenous  vaccine  should  be  eventually  favorable.  The  occasional 
development  of  a  furuncle  is  to  be  expected,  but  its  duration  will  be 
shorter,  the  tenderness  less,  and  solution  and  resolution  m.ore  rapid. 
A  moderate  dose  of  vaccine  is  sufficient  to  abort  a  new  furuncle  if  given 
at  the  opportune  moment. 

In  the  course  of  the  last  two  years  the  writer  has  had  under  treatment 
something  less  than  200  cases  of  localized  staphylococcus  infections, 
and  feels  able  to  speak  with  confidence  of  the  efficacy  of  appropriate 
bacterial  vaccines  properly  applied  in  the  control  of  these  infectious 
processes. 

Guidance  of  Treatment. — The  use  of  the  opsonic  index  is  generally 
unnecessary,  if  one  has  a  thorough  appreciation  of  what  Wright  terms 
the  correlation  that  is  known  to  exist  between  the  condition  of  the 
opsonic  resistance  and  the  clinical  condition  of  the  patient  and  his  lesions. 
The  induction  of  a  negative  phase,  that  is,  a  period  of  lowered  opsonic 
power,  of  lowered  resistance,  in  fact,  by  the  use  of  improperly  large  doses 
of  vaccine,  is  signalized  almost  at  once  by  local  changes  in  the  lesions, 
which  give  information  that  the  process  is  on  the  increase.  We  find 
that  local  tenderness  increases,  inflammation  extends,  discharge  becomes 
increased  in  amount,  and  there  may  be  malaise,  headache,  and  local  pain. 
New  furuncles  may  start  within  a  few  hours  of  the  inoculation.     The 


7l6  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

presence  of  these  manifestations  means  that  a  condition  of  lowered 
opsonic  resistance  has  been  induced  by  the  injection,  as  has  been  suf- 
ficiently well  shown  by  many  observers.  The  opsonic  index  gives  a 
cue  to  the  efficiency  of  the  antibacterial  substances  in  the  circulating 
blood,  but  the  clinical  conditions  just  described  give  one  about  as  efficient 
information  as  to  the  state  of  antibacterial  resistance. 

If  the  condition  of  lowered  resistance  gives  evidence  of  continuance 
by  persistence  of  the.  local  manifestations  described  for  over  b,venty- 
four  hours,  the  dosage  given  was  too  large.  This  does  not  mean  that 
if  the  patient  is  left  alone  the  antibacterial  mechanism  will  not  recover 
itself  and  improvement  become  manifest  after  a  few  days.  It  does 
mean,  however,  that  if  another  injection  is  given  too  soon,  the  same 
condition  may  again  supervene.  We  must  in  such  a  case  await  the 
oncome  of  spontaneous  improvem.ent,  as  shown  by  local  conditions, 
and  then  start  with  a  much  smaller  dose.  There  should  be  such  proper 
adjustment,  size,  and  interval  of  dose  as  to  produce  a  slight  exacerbation, 
if  any,  in  the  first  twelve  hours  after  inoculation,  followed  by  some 
improvement  in  the  next  twenty-four  hours,  and  considerably  more 
improvement  in  the  following  day.  By  the  third  day  a  slightly  larger 
dose  may  be  given,  and  three  or  four  days  later,  perhaps,  a  still  larger 
dose;  then,  if  consistent  improvement  is  taking  place,  the  interval  may 
be  increased  to  four  or  five  days,  being  careful  not  to  use  a  dose  of  such 
a  size  as  will  produce  an  exacerbation  of  long  duration. 

Local  Effects  of  Inoculation. — If  the  proper  vaccine  is  used,  and  it 
may  be  either  autogenous  or  a  commercial  vaccine  of  exactly  the  same 
character  as  the  infecting  organism,  there  will,  in  a  few  hours,  develop 
at  the  point  of  inoculation  an  area  of  redness  and  slight  induration 
and  tenderness.  The  duration  and  severity  of  this  reaction  depend 
to  some  extent  on  the  size  of  the  dosage.  It  is  always  more  marked  in 
the  early  stages  of  treatment,  and  as  the  lesion  improves  and  the  dosage 
is  pushed  higher,  the  reaction  may  disappear  altogether,  only  to  reap- 
pear if  excessively  large  doses  are  used.  In  the  absence  of  any  local 
reaction  after  repeated  inoculation  of  a  sufficient  dose  of  vaccine  one 
is  almost  justified  in  concluding  that  the  infective  process  is  due  to  some 
other  organism  than  that  which  his  vaccine  contains. 

What  harm  can  large  doses  of  vaccine  do  in  these  cases?  If  we 
desire  to  obtain  from  our  treatment  the  maximum  good,  with  the  mini- 
mum of  discomfort  and  unpleasant  symptoms  in  our  patients,  we  should 
guard  against  using  large  doses  when  smaller  ones  will  accomplish  the 
same  results.  If,  being  ourselves  convinced,  it  is  our  desire  to  further 
the  interests  of  specific  therapy,  we  can  ill  afford,  by  injudicious  use 


LOCALIZED  STAPHYLOCOCCIC  INFECTIONS  717 

of  vaccines,  to  furnish  a  foundation  in  the  lay  mind  for  the  idea  that 
vaccines  are  often  brilliant  in  their  results,  but  that  one  never  can  tell 
how  much  good  they  will  do;  that  they  will  certainly  make  one  sick 
before  they  make  him  well,  as  some  of  the  victims  of  ill-conducted 
vaccine  therapy  have  confided  to  the  writer.  We  cannot  always  avoid 
the  mistakes  of  too  large  doses,  but  we  can  make  it  a  rare  'occurrence. 

If  the  dose  is  not  too  large,  it  may  be  given  too  frequently.  The 
patient  may  not  suffer  any  great  increase  in  discomfort,  and  the  lesions 
may  not  grow  much  worse,  but  remain  about  stationary  from  day  to 
day.  To  illustrate:  A  patient  was  referred  to  the  writer  because  he 
had  failed  to  recover  completely  from  a  carbuncle  on  the  neck  and 
scalp.  Vaccine  had  been  given  for  two  months,  but  there  was  still  a 
large  area  of  induration  and  some  discharge  of  deep-lying  pus.  Inquiry 
revealed  the  fact  that  400,000,000  of  staphylococcus  aureus  had  been 
given  every  other  day  for  a  long  period  and  daily  for  two  weeks.  Vac- 
cines were  withheld  for  five  days,  and  then  the  same  dosage  given  less 
frequently.  In  two  weeks  the  induration  had  cleared  up,  and,  except 
for  a  superficial  pustule,  was  well.  In  this  case,  and  in  others  where 
dosage  is  too  large  and  too  frequent,  the  clinical  picture  is  corroborative 
of  what  would  naturally  be  expected — i.  e.,  an  almost  continuous  negative 
phase  or  condition  of  lowered  resistance  to  the  infection.  It  is  a  con- 
dition of  hyperexcitation  of  the  antibody-forming  mechanism,  from 
which  the  organism  does  not  recover  until  the  exciting  agent  is  removed. 

There  can  be  no  hard-and-fast  rule  as  to  the  interval  between  dosage; 
it  depends  on  the  size  of  the  dosage,  the  vaccinating  qualities  of  the 
vaccine,  and  the  manner  in  which  the  patient  responds.  Some  writers 
whose  experience  has  been  large  say  that  an  interval  of  three  days  is 
proper.  No  doubt  there  is  a  dose  which,  if  given  at  three-day  intervals 
in  a  given  case,  will  be  followed  by  satisfactory  results,  but  the  size  of  the 
dose  eflScient  at  this  interval  will  differ  in  different  patients  and  with 
different  vaccines.  It  should  be  the  desire  to  so  adjust  the  dosage  that 
there  should  be  as  short  a  period  of  negative  phase — ^with  its  lowered 
resistance — as  possible,  consistent  with  the  production  of  a  positive 
phase — the  period  of  elevated  resistance — of  as  long  duration  as  possible. 
Patients  and  the  vaccines  are  variable  factors,  and  the  doses  must  be 
adjusted  so  that  the  maximum  benefit  may  be  derived  during  the  period, 
whatever  it  may  be,  between  inoculations.  In  the  early  treatment  of 
cases  the  interval  may  be  one  or  two  days,  because,  in  order  to  avoid 
the  exacerbation  which  would  result  from  a  long-continued  negative 
phase,  the  early  dosage  is  small.  The  smaller  the  dose,  the  shorter 
the  duration  of  the  negative  phase.     At  the  same  time,  the  positive 


7l8  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

phase  will  be  of  brief  duration.  Hence,  at  first,  to  avoid  exacerbation, 
small  doses  should  be  given  frequently,  and  as  improvement  becomes 
evident,  the  doses'  are  made  larger  and  less  frequent.  In  furunculosis 
the  interval  of  dosage  in  a  given  case  may  vary  from  one  to  six  or  more 
days,  depending  on  the  stage  of  treatment. 

Acne. — The  pustular  type  of  acne  may  be  compared  to  a  chronic 
furunculosis  of  the  face,  and  is  commonly  amenable  to  vaccine  treatment 
if  properly  conducted.  The  etiologic  factor  is  the  staphylococcus 
aureus  or  albus;  if  together,  the  albus  usually  predominates;  more 
commonly,  the  albus  will  be  found  singly  in  practically  pure  culture  in 
the  pus  from  the  lesions. 

Kind  of  Vaccine. — A  vaccine  prepared  of  equal  parts  of  Staphylo- 
coccus aureus  and  albus  from  \drulent  stocks  is  commonly  satisfactory 
in  the  treatment  of  these  cases,  but  it  will  be  found  that  an  autogenous 
vaccine  frequently  gives  better  results  than  such  a  stock  vaccine. 

Duration  of  Treatment. — Some  cases  will  clear  up  after  t^vo  or  three 
months  of  careful  treatment,  and  with  only  occasional  subsequent  de- 
velopment of  new"  lesions.  A  few  cases  will  be  absolutely  cured.  One 
should  not  be  discouraged  if,  after  two  or  three  months'  treatment,  there 
is  definite  improvement,  but  not  a  cure.  Persistence  will  often  bring 
final  success.. 

Dosage. — At  first  100,000,000  to  200,000,000  may  be  given,  and  re- 
peated in  five  or  six  days.  An  increase  of  from  50,000,000  to  100,000,000 
at  each  dose  should  be  made  up  to  the  limit  of  1,000,000,000,  although 
the  writer  has  only  rarely  found  it  necessary  to  give  more  than  500,000,000. 
Quite  as  good  results  have  been  achieved  with  such  a  dose  given  once 
in  five  or  six  days.  A  smaller  dose,  however,  given  twice  a  week,  has 
oftentimes  improved  the  condition  where  a  larger  dose,  given  once  in 
six  days,  was  followed  each  time  by  an  exacerbation. 

If  the  vaccine  is  given  properly,  a  gradual  improvement  should  be 
e^ddent.  Relapses  are  very  common,  however.  The  result  of  treat- 
ment depends  fundamentally  on  the  proper  adjustment  of  size  and 
interval  of  dose.  A  given  dose  would  seem  to  be  correct  if,  on  the  day 
following  its  administration,  one  or  two  new  lesions  begin  to  appear, 
but  in  the  next  few  days  disappear,  with  an  accompanying  improvement 
in  the  other  older  lesions.  Such  a  dose  may  be  continued  until  it  is 
•found  that,  on  the  day  following  the  dose — i.  e.,  in  the  period  of  negative 
phase,  which  is  characterized,  of  course,  by  diminished  phagocytic  resis- 
tance— there  are  no  new  lesions,  but  that  an  immediate  improvement 
follows,  and  then,  in  the  two  days  before  the  next  dose,  new  lesions  appear. 
Under  such  conditions  it  is  evident  that  the  patient  is  becoming  tolerant; 


ACNE    AND   CARBUNCLE  719 

that  the  vaccine  is  producing  an  immediate  positive  phase,  but  that  the 
continuance  of  the  positive  phase  is  consequently  short.  We  must, 
therefore,  increase  the  dose  until  it  will  produce  a  negative  phase. 

Ordinarily,  if  a  dosage  of  staphylococcus  vaccine  does  not  produce 
any  local  reaction  when  given  just  subcutaneously,  either  the  vaccine 
is  not  the  correct  one  or  the  dosage  is  not  sufficiently  large.  Local 
reactions  at  the  point  of  inoculation  are  undoubtedly  specific  reactions, 
and  if  present,  they  not  only  indicate  that  the-  patient  is  sensitized  to 
the  particular  organism  injected,  but  also  that  there  exists  a  certain 
capability  of  resistance. 

Whitfield^  says,  concerning  acne,  "The  treatment  is  uncertain;  in 
some  cases  most  brilliant,  in  others  without  the  slightest  avail."  This 
appears  to  be  the  consensus  of  opinion  among  those  who  are  dealing 
with  considerable  numbers  of  these  cases,  particularly  in  the  chronic 
type  of  acne  vulgaris,  which  runs  for  years,  accompanied  by  comedone 
formation,  deep-lying  nodules,  pustules,  and  areas  of  induration.  Fre- 
quently there  is  temporary  improvement,  but  relapses  are  common,  and 
the  fundamental  nodular  inflammatory  condition  m.ay  continue  un- 
abated. In  view  of  this  fact  it  seems  probable  that  the  staphylococcus 
may  not  be  in  all  cases  the  etiologic  factor.  Unna,  in  1893,  found  in 
smears  from  comedones  and  pustules  a  bacillus  in  large  numbers. 
Sabouraud  was  able  to  grow  it,  and  later  Gilchrist  expressed  the  opinion 
that  it  was  the  cause  of  acne  vulgaris. 

Pioneer  work  in  the  treatment  of  acne  by  this  bacillus  has  been 
done  by  Fleming  ^  in  Wright's  clinic  in  London.  Perusal  of  his  investiga- 
tions would  lead  one  to  beheve  that  the  so-called  acne  bacillus  is  the 
probable  cause  of  the  disease;  that  it  is  an  important  factor  in  producing 
all  types  of  the  lesions;  that  staphylococcus  may  be  associated  with  it 
in  the  production  of  pustules;  and  that  treatment  by  vaccine  derived 
from  the  acne  bacillus,  used  in  association  with  staphylococcic  vaccine, 
promises  better  results  than  have  heretofore  been  obtained. 

Carbuncle. — The  proper  use  of  vaccines  in  the  treatment  of  car- 
buncle can  in  almost  every  case  be  relied  upon  decidedly  to  modify 
the  surgical  necessities,  and  sometimes  even  to  render  surgical  inter- 
vention unnecessary;  in  almost  all  cases  (the  exceptions  being  aged 
people  or  others  who,  for  one  reason  or  another,  do  not  react  to  the  in- 
oculations of  vaccine)  the  use  of  vaccines  will  distinctly  modify  and 
limit  the  course  of  the  disease  after  operation. 

The  problem  of  treatment  is  more  complicated  than  that  of  simple 

*  Trans.  Sixth  International  Dermatological  Congress,  1907. 
^Lancet,  April  10,  1909;  Brit.  Med  Jour.,  August,  1909. 


720  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

furuncle,  for  the  following  reasons:  First,  carbuncle  of  considerable 
size  is  commonly  associated  with  fever,  which,  of  course,  indicates  that 
bacteria  and  their  poisons  are  being  taken  up  by  the  blood-stream; 
that  is,  there  is  more  or  less  continuous  autoinoculation  taking  place. 
Second,  whereas  in  furuncle  the  pus  and  necrotic  material  is  ordinarily 
localized  in  a  single  pocket,  and  may  be  given  efficient  vent  by  a  simple 
incision,  in  carbuncle  we  have  a  more  generalized  necrosis  and  infiltra- 
tion of  the  tissues  with  pus;  incision  drains  the  immediate  vicinity,  but 
only  that.  Third,  the  tissues  seem  to  offer  little  resistance  to  the  ex- 
tension of  the  process  downward  and  laterally;  in  other  words,  there  is 
apparently  an  absence  of  the  tendency  toward  walling  off  which  is  so 
evident  in  furuncle.  This  may  be  due  to  the  virulence  of  the  infecting 
organisms  and  to  the  tryptic  or  dissohdng  power  of  the  pus  (a  product 
of  the  broken-down  leukocytes) ,  by  which  it  dissolves  the  fat  and  connec- 
tive tissue  and  thus  extends.  Fourth,  the  circulation  of  the  blood, 
upon  which  the  body  depends  for  the  destruction  of  invading  organisms, 
is  cut  off  everywhere  excepting  at  the  extreme  limits  of  the  extending 
process,  but  even  here  the  coagulation  of  lymph  and  the  exudation 
tend  to  nullify  the  attempts  of  the  body  to  furnish  a  suitably 
increased  blood-supply. 

These  factors  are  particularly  notable  in  certain  locations,  such  as 
the  back  of  the  neck,  where  the  columnee  adiposas,  by  their  anatomic 
relations,  divide  the  subcutaneous  tissue  into  numerous  cells  with 
connective-tissue  walls.  We  should,  therefore,  expect  that  where  a 
carbuncle  exists  in  this  location,  extensive  surgical  measures  would  be 
more  necessary  than  in  other  parts  of  the  body,  and  this  is  actually  the 
case.  If,  wherever  the  carbuncle  is  located,  there  is  shown  by  elevation 
of  the  infected  area  above  the  normal  skin  surface  a  tendency  toward 
walling  off,  the  extent  of  the  surgical  requirements  will  be  consider- 
ably lessened.  If  the  infection  is  infiltrating  and  the  tissue  is  brawny 
and  not  raised  above  the  surface,  thus  indicating  a  defective  wall- 
ing off,  surgical  measures  are  of  inunediate  and  paramount  impor- 
tance. 

In  aU  cases  the  quickest  method  to  promote  recovery  will  be  to  in- 
stitute the  freest  possible  drainage,  by  means  of  incision  or  excision, 
followed  by  the  use  of  staphylococcus  aureus  vaccines.  Where  vaccines 
are  to  be  employed,  the  surgical  procedures  may  safely  be  considerably 
less  extensive  than  would  otherwise  be  indicated.  This  is  of  particular 
advantage  if  the  patient's  condition  does  not  warrant  etherization  and 
extensive  operation,  or  if  there  exists  a  particular  reason  for  avoiding 
a  noticeable  or  disfiguring  scar.     The  employment  of  vaccines  will  in 


CARBUNCLE   OF   THE  NECK  72 1 

most  cases  result  in  a  more  rapid  recovery,  with  less  disfigurement,  than 
if  surgical  measures  alone  have  been  used. 

If,  in  carbuncle  of  the  neck,  when  first  seen,  the  infection  is  extensive, 
without  any  discharging  opening,  the  indications  are  surgical,  namely, 
excision  or  crucial  incision  and  removal  of  necrotic  tissue,  and  the  pack- 
ing of  the  wound  with  gauze  wet  in  Wright's  sodium  citrate  and  sodium 
chlorid  solution.  A  culture  should  be  immediately  taken  with  the  in- 
tention of  preparing  an  autogenous  vaccine.  There  will  usually  be  an 
exacerbation  in  temperature  following  the  operation,  due,  of  course,  to 
the  autoinoculation  which  the  operative  procedure  has  induced.  The 
dressing  should  be  kept  continuously  moist  and  changed  every  few 
hours.  There  will  be,  in  a  few  hours,  a  profuse  purulent  discharge.  A 
flaxseed  poultice,  constantly  applied  over  the  citrate  dressing,  will  be 
found  distinctly  advantageous  in  that  it  increases  the  blood-supply 
to  the  part.  After  twenty-four  hours  the  tenderness  at  the  edges  of  the 
carbuncle  should  be  considerably  less  and  the  temperature  should  be 
somewhat  lower. 

The  injection  of  vaccine  should  be  delayed  until  the  effect  of  the 
surgical  autoinoculation  has  worn  itself  out.  Ordinarily,  by  the  third 
day  after  operation,  the  temperature  will  have  become  practically 
normal,  and  the  opsonic  index,  if  determined,  will  be  found  normal  or 
elevated.  At  this  time  a  small  dose  of  vaccine,  perhaps  100,000,000, 
is  indicated;  two  days  later  it  should  be  repeated,  and  three  to  four 
days  subsequently  increased  to  200,000,000.  If,  on  the  third  day 
following  operation,  the  temperature  is  still  elevated,  it  means  that 
the  opsonic  power  is  deficient,  but  suggests  that  the  dose  of 
vaccine  should  be  made  small,  in  order  not  further  to  depress 
the  resistance.  In  a  febrile  case  the  dosage  would  ordinarily  be 
50,000,000,  repeated  daily  until  the  temperature  is  normal,  then  increased 
to  100,000,000  every  other  day,  and  then  further  increased,  as  indicated, 
with  an  accompanying  increase  in  the  interval  between  the  doses.  The 
sodium  citrate  dressings  should  be  continued  only  until  the  wound  is 
clean  and  has  begun  to  granulate;  thereafter  the  wound  may  be  packed 
with  sterile  gauze  or  with  gauze  impregnated  with  balsam  of  Peru  or 
some  antiseptic  powder.  The  urine,  of  course,  must  be  examined  for 
sugar,  the  presence  of  which  is  commonly  accompanied  by  a  lowered 
opsonic  resistance  to  staphylococcus  and  with  a  predisposition  toward 
such  infection.  Inoculation  may  properly  be  continued  every  four  or 
five  days  until  the  wound  is  clean.  The  patient  should  be  advised  on 
discharge  to  report  for  inoculation  whenever  the  slightest  suspicion  of 
recurrence  develops. 

46 


722 


THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 


If  a  carbuncle  is  small,  say,  not  more  than  two  inches  in  diameter, 
the  surgical  requirements  may  be  merely  multiple  deep  puncture  with 
a  small  bistoury,  provided  it  is -desired  to  minimize  the  scar.  This 
should  be  followed  by  active  cupping  with  Bier's  apparatus  for  two  to 
five  minutes,  and  with  the  application  of  sodium  citrate  and  chlorid 
solution,  surmounted  by  a  hot  flaxseed  poultice.  A  certain  amount  of 
autoinoculation  is  produced  by  the  punctures;  at  the  same  time  a  free 
streaming  of  serum  is  induced  into  the  infected  focus  by  the  cupping. 
The  citrate  and  salt  solution  keeps  the  exit  for  the  discharge  of 
serum  free  from  crusting,  and  the  heat  of  the  flaxseed  poultice  brings 
increased  amount  of  blood  to  the  part,  all  of  which  conditions  tend  to 
bring  to  bear  in  the  infected  focus  the  sum  total  of  the  antibacterial 
power  which  the  patient  can  direct  against  the  infecting  organisms. 
Cupping  may  be  repeated  every  few  hours.  Vaccine  should  be  given 
according  to  principles  previously  outlined.  After  forty-eight  hours 
there  should  be  a  free  discharge  from  most  of  the  openings  made,  and 
the  progress  toward  recovery  should  be  consistent.  If  the  slough  does 
not  liquefy  and  discharge  itself  easfly,  this  will  have  to  be  facilitated  by 
cutting  with  scissors  the  bridges  of  skin  between  a  number  of  the  dis- 
charging openings.  It  is  quite  remarkable  that,  after  poulticing  for 
forty-eight  hours  with  citrate  solution,  these  bridges  of  skin  may  be  cut 
with  very  little  pain  to  the  patient. 

On  the  face,  the  ideal  to  be  aimed  at  is  to  produce  as  little  disfigure- 
ment as  possible.  In  the  writer's  experience,  carbuncles  on  the  face  have 
never  required  excision.  There  is  commonly  found  one  or  more  small 
pustules  where  the  pus  has  burrowed  toward  the  surface;  the  necrotic 
skin  covering  these  pustules  should  be  cut  away,  that  the  discharge 
may  be  free.  A  sodium  citrate  solution  is  applied  in  the  usual  manner, 
and  over  it  a  hot  flaxseed  poultice.  An  immediate  inoculation  is  usually 
given  of  from  25,000,000  to  50,000,000  staphylococci  (aureus).  This  is 
followed  in  twenty-four  hours  by  a  dose  of  equal  size,  and  on  the  follow- 
ing day  75,000,000  or  100,000,000  may  be  injected.  After  twenty-four 
hours  ordinarily  there  will  appear,  in  addition  to  tiie  discharging  open- 
ings seen  at  first,  a  considerable  number  of  small,  superficial  pustules, 
corresponding  with  the  mouths  of  the  hair-follicles.  These  are  each 
pricked,  and  as  much  discharge  expressed  as  possible.  Each  day  this 
procedure  is  carried  out.  By  the  third  day  the  temperature  may  have 
reached  normal,  and  the  discharge  ha^'e  increased.  At  this  stage  it  will 
be  possible  to  provide  for  a  larger  opening  by  cutting  some  of  the  epi- 
thelial bridges  with  scissors  and  thus  give  exit  to  the  slough.  At  the 
end  of  five  or  six  days  the  wound  should  be  clean  and  granulating. 


CARBUNCLE   OF   THE   BACK  723 

The  vaccines  are  given  every  other  day,  after  the  first  three  or  four  days, 
and  then  at  longer  intervals  until  the  crater  is  entirely  closed  in.  After 
the  first  four  doses,  generally  given  daily,  one  or  two  doses  may  be 
skipped.  Rarely  is  it  necessary  to  administer  more  than  200,000,000  or 
300,000,000  at  a  dose  as  the  recovery  progresses.  In  a  half-dozen  cases 
of  facial  carbuncle  that  the  writer  has  treated  the  resulting  scar  has  been 
scarcely  noticeable. 

Carbuncle  of  the  hack  has  been  commonly  treated  by  excision.  From 
the  cases  which  the  writer  has  treated  he  has  come  to  the  conclusion 
that  excision  is  rarely  necessary,  and  that  limited  incision  is  sufficient 
unless  the  carbuncle  is  widely  extensive. 

An  illustrative  case  is  that  of  a  man  of  fifty  years  of  age,  admitted  to  the 
Boston  City  Hospital  mth  three  carbuncles  on  the  back,  one  of  them  over  the 
left  scapula,  the  size  of  the  palm,  one  a  little  lower  down,  slightly  smaller,  and 
one  over  the  other  scapula,  about  t^vo  inches  in  diameter,  v/ith  a  duration  of 
about  a  week.  The  temperature  was  102  °  F.,  and  there  was  not  much  malaise. 
At  several  points  the  pus  was  burro^Aing  to  the  surface,  but  there  was  no 
discharge.  The  urine  contained  considerable  sugar.  The  pustules  were 
pricked,  and  the  carbuncles  kept  constantly  covered  with  salt  and  sodium 
citrate  poultices.  Inoculation  was  given  on  the  first  day  of  75,000,000  stock 
staphylococcus  aureus  vaccine,  and  then  every  other  day  a  dose  of  100,000,000 
was  injected.  Within  forty-eight  hours  all  the  carbuncles  had  begun  to  dis- 
charge profusely.  By  means  of  scissors  the  different  openings  which  had 
developed  were  connected.  Inside  of  a  week  the  lesions  had  cleaned  up.  In 
ten  days  aU  the  carbuncles  had  begun  to  granulate  in.  At  this  time  the 
patient  was  placed  upon  a  diabetic  diet.  The  patient  was  seen  three  months 
later,  and  all  the  evidence  of  carbuncle  was  a  scar  about  the  size  of  a  thumb- 
nail at  the  site  of  the  larger  lesion,  and  two  other  scars  v/ere  about  one-quarter 
this  size.  The  antidiabetic  diet  had  not  been  persisted  in.  It  is  interesting 
to  note  that  the  back  was  covered  vvith  small  pustules  as  a  result  of  the  irrita- 
tion of  the  citrate  and  salt  solution,  which  cleared  up  as  soon  as  the  solution 
was  omitted. 

The  advantage  of  Wright's  sodium  citrate  and  chlorid  solution  in 
the  treatment  of  localized  discharging  infections  cannot  be  over- 
emphasized. We  must  realize  that  in  immunizing  the  patient  we  must 
make  use  of  every  measure  which  may  be  calculated  to  aid  in  any  way 
the  physiologic  mechanism  that  the  body  directs  against  bacteria. 
The  use  of  antiseptics  is  to  be  condemned.  The  fact  that  this  solution 
provides  for  a  free  and  continued  circulation  of  lymph  through  the 
infected  focus  must  place  it  as  one  of  the  most  important  aids  that  we 
have  in  the  cure  of  localized  infectious  processes. 


724  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

Hmpyema. — The  commonest  causes  of  empyema  are  pneumococcus 
and  streptococcus.  Where  drainage  is  free  in  adults,  there  is  commonly 
little  need  of  offering  assistance  to  the  patient  in  immimizing  himself. 
If  the  discharge  continues,  it  is  very  often  due  to  poor  drainage.  Certain 
cases,  however,  continue  to  have  a  discharge  which  may  be  attributed 
to  a  lack  of  immunizing  power.  Such  cases  will  be  apt  to  show  elevation 
of  temperature,  considerable  discharge,  and  an  opsonic  index  to  the 
organism  present  v'hich  is  below  normal.  In  such  cases  bacterial 
vaccines  are  indicated. 

Although  several  cases  of  pneumococcous  empyema  have  come  to 
the  writer's  attention  with  a  question  of  the  ad\isability  of  vaccine, 
it  was  found  in  all  cases  that  the  patient  finally,  in  a  fairly  short  time, 
immunized  himself  and  vaccines  were  unnecessary,  although  they  might 
have  hastened  the  result.  The  dosage  of  pneumococcous  vaccine  in 
such  cases  may  be  from  10,000,000  to  100,000,000  or  more,  bearing 
in  mind  the  axiom  that  the  sicker  the  patient,  the  smaller  the  dosage 
that  should  be  used.  This  means  that  if  there  is  a  temperature  the 
minimal  dose,  repeated  in  tweh^e  to  t^venty-four  hours,  will  be  indicated. 
If  there  is  no  temperature,  and  the  general  condition  of  the  patient  is 
good,  slightly  larger  doses  may  be  given  every  day,  or  every  other  day, 
with  a  gradual  increase  in  dosage  and  in  interval.  Where  the  empyema 
is  due  to  other  organisms,  such  as  streptococcus,  or  where  a  mixed 
infection  is  found,  appropriate  autogenous  vaccines  should  be  made  and 
used  if  indicated.  About  one-half  the  cases  of  empyema  in  adults  are 
said  to  be  due  to  streptococcus. 

Dr.  Cleaveland  Floyd^  reports  6  cases  of  empyema  in  children,  in  which 
he  considers  that  extremely  favorable  results  were  obtained.  He  has  noted 
an  immediate  control  over  the  course  of  the  disease  and  a  decided  improve- 
ment in  the  condition  of  the  patient. 

Briscoe  and  Williams^  report  a  case  of  empyema  in  a  child  of  two,  in 
which  pneumococcus  was  the  cause  and  to  which  vaccine  therapy  was  applied; 
10,000,000  killed  organisms  were  given,  and  eight  days  later  40,000,000. 
Their  opinion  was  that  the  temperature  was  diminished  and  the  general  con- 
dition improved. 

Allen^  states  that  good  results  may  be  anticipated  in  empyema ta  when 
vaccine  therapy  is  directed  against  organisms  found  present;  that  there  is 
apt  to  be  a  mixed  infection  and  that  a  inixed  vaccine  should  be  employed; 
that   improvement    may   be    slow   and   prolonged   treatment   necessary'.     If 

^  Boston  Med,  and  Surg.  Jour.,  1908,  chiii,  5. 

^  Pract.,  London,  May,  1908,  675. 

^Vaccine  Therapy  and  Opsonic  Treatment,  1908,  170. 


OSTEOMYELITIS  725 

streptococcus  is  found,  the  dose  will  be  from  10,000,000,  as  a  minimum,  to 
50,000,000  or  100,000,000. 

Empyemata  of  the  accessory  air-cavities,  where  they  do  not  respond 
to  ordinary  treatment,  would  naturally  come  wdthin  the  scope  of  vac- 
cine therapy. 

Osteomyelitis. — In  acute  osteomyelitis,  after  drainage  has  been 
assured  and  the  temperature  reaches  normal,  there  may  be  advantage 
in  giving  staphylococcus  or  other  vaccine  as  indicated  by  culture.  There 
are  no  statistics  by  which  one  can  prove  that  a  continuously  elevated 
opsonic  index  after  such  condition  will  hasten  cure,  but  it  seems  reason- 
able that  such  would  be  the  case. 

In  certain  cases  the  tendency  of  the  infection  is  to  continue  in  the  soft 
tissues,  producing  a  profuse  discharge.  Such  infections  may  be  definitely 
controlled  by  vaccine.  As  an  example  of  such  a  case  I  may  cite  one  referred 
by  the  author  of  this  volume,  who  had  osteomyelitis  of  the  terminal  phalanx 
of  the  thumb.  Incision  had  been  made  and  dead  bone  found,  but  was  not, 
however,  removed.  For  a  month  there  were  two  discharging  sinuses  and 
a  very  severe  infection  of  the  soft  tissues  of  the  thumb.  Inoculations  of 
100,000,000  were  given  every  three  or  four  days,  gradually  increasing  to 
300,000,000  at  five-day  intervals.  At  the  end  of  two  weeks  the  thumb  had 
decreased  remarkably  in  size  and  the  discharge  was  much  less.  After  three 
months'  treatment  about  one-half  of  the  terminal  phalanx  was  discharged,  and 
within  ten  days  the  sinuses  healed. 

Where  discharging  sinuses  are  all  that  is  left  of  the  disease,  the  use 
of  vaccine,  associated  with  measures  to  produce  a  determination  of  lymph 
into  the  sinuses  (as  described  under  Treatment  of  Sinus) ,  has  proved 
a  reliable  means  of  hastening  recovery. 

It  has  always  seemed  best  to  the  writer,  in  this  as  well  as  other  ful- 
minating infections,  to  interfere  as  little  as  possible  during  the  active 
febrile  period;  that  persisting  temperature  in  most  cases  means  insuf- 
ficient drainage  or  new  foci  forming  in  other  parts.  Certainly,  in  these 
conditions,  vaccine  cannot  hope  to  compete  with  the  measures  calculated 
to  produce  free  drainage.  Vaccine  may  be  given  during  the  febrile  period 
if  it  is  held  down  to  extremely  minute  doses,  as  10,000,000  to  50,000,000 
staphylococci  daily,  or  1,000,000  to  10,000,000  streptococci,  as  the  case 
may  be,  but  in  the  writer's  experience  it  is  a  better  course  to  rely  on  free 
drainage  and  the  patient's  own  powers  to  immunize  himself  at  first,  and 
then,  if  conditions  indicate  that  he  is  incompetent  to  do  so,  the  ex- 
hibition of  vaccine  is  decidedly  indicated. 


726  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

Infected  Sinuses. — A  successful  outcome  in  the  treatment  of  tu- 
berculous lesions  associated  with  discharging  sinuses  depends  often  upon 
the  way  in  which  any  secondary  infection  of  the  sinus  itself  is  treated. 
There  are  many  cases  in  w^hich  the  sinus  is  infected  by  Staphylococcus 
pyogenes  albus,  which  is  apparently  of  little  virulence,  and  which  the 
writer  has  been  in  the  habit  of  neglecting,  unless  it  is  evident  that  its 
growth  produces  irritation  and  increases  the  discharge.  The  use  of 
the  opsonic  index  will  give  one  a  cue  as  to  whether  such  an  infection 
needs  treatment.  If  the  opsonic  index  is  found  to  be  repeatedly  low — ■ 
that  is,  below  0.75 — it  is  reasonable  to  endeavor,  by  means  of  an  auto- 
genous vaccine,  to  elevate  the  index  to  above  normal  and  maintain  it  so 
for  as  long  as  possible.  Where  staphylococcus  pyogenes  aureus,  or 
streptococcus,  or  other  pathogenic  organisms  are  found,  it  is  practically 
certain  that  a  vaccine  will  be  the  best  method  of  treatment.  An  auto- 
genous vaccine  should  always  be  used,  particularly  in  the  case  of  strepto- 
coccus or  colon  bacillus. 

Oftentimes,  although  the  lesion  at  the  base  of  the  sinus  may  be  dis- 
charging little,  there  may  be  a  copious  discharge,  originating  in  an  infec- 
tion of  its  walls.  The  organisms  in  the  sinus  walls  have  decidedly 
suitable  culture  ground  for  their  growth.  They  are  walled  off  from 
active  blood-supply  by  the  fact  that  they  are  located  within  a  tube,  as 
it  were,  of  rather  dense  connective  tissue,  in  the  interior  of  which  there 
is  plenty  of  such  food  material  as  coagulated  fibrin  and  broken-down 
tissue  and  detritus.  It  is  obviously  necessary,  in  the  first  place,  to  do  what 
we  can  to  bring  a  supply  of  fresh  serum  to  the  part,  and,  in  the  second 
place,  to  provide  for  its  free  exit,  in  order  that  continuously  fresh  serum 
may  come  into  contact  with  the  bacteria.  Wright's  treatment  of  such 
a  sinus  is  irrigation  with  the  solution  of  salt  and  citrate,  previously 
described,  which  prevents  coagulation  of  lymph  and  secondary  plugging 
of  the  sinus,  and  will,  by  osmosis,  draw  serum  to  the  part  and  bring 
it  into  contact  with  the  bacteria  which  it  is  our  purpose  to  destroy. 
Besides  the  syringing,  it  will  be  best  in  many  cases  to  apply  to 
the  opening  of  the  sinus  gauze  pressings,  wet  in  the  same  solu- 
tion, being  careful  first  to  cover  the  normal  skin  thickly  with  boric 
ointment. 

The  dosage  of  vaccine  in  these  case's  often  exceeds  that  of  the  other 
lesions  infected  by  corresponding  bacteria,  because  the  organisms  are 
so  well  walled  off  from  the  circulation,  and  it  may  be  necessary  to  prolong 
treatment  over  a  considerable  period.  Sinuses  that  lead  to  glands  which 
have  been  infected  with  streptococcus,  even  if  the  glands  have  been 
removed,  are  apt  to  discharge  for  a  long  time. 


ERYSIPELAS  727 

As  an  illustration,  a  woman  twenty-five  years  of  age  had  a  furuncle  in  the 
auricle  excised.  She  developed  subsequently  enlarged  glands  in  the  neck, 
several  of  which  suppurated,  requiring  a  number  of  incisions  for  sufficient 
drainage.  For  three  months,  in  spite  of  autogenous  streptococcus  vaccine  in 
moderate  dosage  up  to  100,000,000,  only  slight  improvement  in  the  discharge 
was  obtained.  A  sudden  attack  of  erysipelas  facialis  developed,  lasting  a  week. 
On  recovery  from  this  attack  every  sinus  immediately  closed  and  the  patient 
has  been  well  ever  since. 

This  would  seem  to  indicate  that  in  dealing  with  chronic  infected 
sinuses,  at  any  rate  those  infected  with  streptococcus,  we  have  an  indica- 
tion for  large  dosage  so  long  as  no  constitutional  symptoms  develop. 
Apparently  in  this  case  the  high  degree  of  immunity  to  the  streptococcus, 
which  developed  accompanying  the  recovery  from  erysipelas,  was  suffi- 
cient to  eradicate  the  streptococci  which  had  been  active  in  the  perpetu- 
ation of  the  infection,  and  upon  which  the  vaccine  in  ordinary  dosage 
had  practically  no  effect. 

!Er5''Sipelas. — The  ordinary  type  of  facial  erysipelas  is  of  so  short 
duration,  and  the  temperature  is  so  likely  to  fall  at  almost  any  time, 
that  observations  as  to  the  efficacy  of  vaccine  until  a  great  many  more 
cases  have  been  reported  will  be  of  little  value.  When,  however,  in  a 
case  of  erysipelas  of  the  spreading  type,  we  find  that  a  series  of  inocula- 
tions will  stop  the  progress  of  the  disease,  we  must  give  vaccine  perhaps 
a  certain  amount  of  credit. 

If  possible,  an  autogenous  vaccine  should  be  prepared,  but  until  it 
can  be  obtained,  a  stock  vaccine  of  several  strains  obtained  from  erysipelas 
cases  is  indicated.     _ 

So  long  as  the  temperature  is  elevated,  we  have  a  condition  of  auto- 
inoculation  which  contraindicates  the  use  of  large  doses  of  vaccines. 
Such  dosage  would  tend  further  to  depress  the  antibacterial  power  of 
the  blood  or  to  maintain  it  in  a  lowered  condition.  We  must,  therefore, 
grade  our  dosage  exactly  as  we  would  in  a  septicemia,  and  be  satisfied 
with  a  slight  rise  in  the  antibacterial  power  and  a  repetition  of  this  rise 
as  often  as  possible.  The  writer's  method  has  been  to  give  daily  inocu- 
lations of  from  2,000,000  to  25,000,000  organisms. 

The  writer  has  treated  four  cases  of  the  migrating  type.  One  of  them,  in 
spite  of  the  vaccine,  developed  patches  in  various  parts  of  the  body  successively, 
practically  cleared  up  twice,  and  finally  had  a  third  relapse.  We  cannot  in 
this  case  say  that  the  vaccine  did  no  good,  but  certainly  it  did  not  effect  a  cure. 
The  other  three  cases,  of  exactly  the  same  type,  previous  to  inoculation  had 
shown  no  tendency  to  limit  themselves,  but  after  several  inoculations,  at  one- 
and  two-day  intervals,  the  process   in    each  case    absolutely  ceased.     The 


728  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

dosage  in  these  cases  may  be  at  daily  interv^als  at  first.  If  more  minute 
doses  are  given,  say  1,000,000  or  10,000,000,  inoculations  may  be  given  once 
in  twelve  hours.  Large  doses  are  decidedly  contraindicated,  as  they  are  in 
any  active  spreading  infection  associated  with  temperature. 

Favorable  cases  are  reported  by  Harris^  and  by  Wynn.^  Weaver  and 
Broughton^  report  22  cases  of  erysipelas  treated  by  means  of  polyvalent 
heterologous  streptococci,  obtained  from  nasal  secretions  of  three  cases  of 
typical  uncomplicated  er}^sipelas,  and  from  typical  spreading  erysipelas. 
Streptococci  from  several  strains  were  grown  on  blood-agar  and  suspended 
in  a  25  per  cent,  galactose  solution  until  sterile,  then  distributed  into  small  test- 
tubes,  centrifugalized,  the  clear  fluid  pipeted  off,  and  the  bacterial  sediment 
desiccated  in  vacuum.  The  bacteria  were  again  suspended  in  an  85  per 
cent,  salt  solution  for  injection.  The  single  dose  contained  200,000,000 
streptococci. 

Of  these  22  cases,  2  were  relapsing,  6  migrating,  and  3  recurrent.  Of  the 
rest,  3  were  mild,  4  moderate,  and  6  severe.  In  only  3  cases  did  the  treatment 
appear  to  have  any  effect,  and  these  were  all  of  the  migrating  t}^e.  In  all 
the  spreading  stopped  within  two  days  and  the  patients  recovered  rapidly. 
In  the  3  cases  known  to  be  recurrent  the  treatment  did  not  prevent  later  re- 
currences. One  case,  which  received  injections,  had  five  attacks  of  facial 
erysipelas  during  eight  months. 

The  eft'ect  of  the  vaccine  at  the  site  of  injection  was  sHght  tenderness  for 
twenty-four  hours  sometimes,  but  no  systemic  efi'ect.  They  conclude  that 
the  injection  of  killed  pol}walent  streptococcus  vaccine  in  the  acute  stage  of 
erysipelas  is  -without  apparent  eft'ect  on  the  course  of  the  disease,  cases  doing 
no  better  than  the  controls  that  have  received  no  injections.  In  the  cases  of 
migrating  type  injections  appear  to  have  a  beneficial  influence.  In  the  re- 
current cases,  they  say  that  it  is  not  unlikely  that  several  injections  might 
finally  produce  immunity  from  further  recurrence,  but  they  were  unable  to 
have  the  patients  under  observation  any  longer  than  during  a  single  attack. 

Sycosis. — This  infection,  which  is  due  to  the  staphylococcus  aureus, 
has  always  been  resistant  to  the  usual  methods  of  treatment.  Scham- 
berg  and  others^  say  that  no  treatment,  save  possibly  the  :x:-ray,  has 
given  in  their  hands  as  good  results  in  cases  of  obstinate  sycosis  as  vac- 
cine therapy.  They  report  i  case  entirely  cured;  2  not  improved;  i 
greatly  improved;  2  slightly  improved;  3  almost  well.  When  these  cases 
are  seen,  they  ha^'e  been  generally  of  long  standing,  and  a  condition  of 
pustulation  is  commonly  superimposed  upon  thickened  and  chronically 
inflamed  skin. 

^  Practitioner,  May,  1908. 

^  Birnungham  Med.  Re\iew,  June,  1908. 

^  Jour.  Infectious  Diseases,  December  18,  1908,  608. 

*  Trans.  Sixth  International  Dermatological  Congress,  1907. 


ECZEMA  729 

In  the  writer's  experience,  early  cases  are  very  amenable  to  vaccine 
treatment.  Measures  must  first  be  taken  to  prevent  crusting,  to  provide 
for  a  free  discharge  from  the  pustules,  and  in  some  active  manner  to  draw 
as  much  blood  to  the  part  as  possible.  The  face  should  be  kept  as  free 
as  possible  from  crusts.  The  pustules  should  be  pricked,  and  the  pustu- 
lar area  washed  frequently  with  ^  per  cent,  sodium  citrate  and  2  per  cent, 
sodium  chlorid  solution,  and  hot  applications  made  continuously  as 
possible  for  two  or  three  hours  twice  a  day. 

Vaccine  should  be  prepared  from  the  patient's  own  organism,  which 
is  usually  staphylococcus  aureus  alone  or  mixed  with  staphylococcus 
albus.  The  aureus,  however,  is  always  the  offending  organism,  and 
the  vaccine  should  be  prepared  from  this.  The  dosage  in  an  adult 
should  be  at  the  start  200,000,000  or  250,000,000,  and  should  be  repeated 
in  four  or  five  days.  Treatment  may  have  to  be  continued  for  from 
one  to  two  months,  although  the  early  cases  may  clear  up  in  half  the 
time.  The  dosage  need  not  be  pushed  higher  than  400,000,000  or 
500,000,000. 

The  immediate  improvement,  after  the  first  one  or  two  doses,  is  so 
marked  that  oftentimes  the  patient  will  feel  that  he  is  immediately  on 
the  road  to  recovery  and  will  stop  treatment.  He  will  be  fairly  sure 
to  relapse  sooner  or  later,  and  will  then  show  up  for  one  or  two  doses 
and  again  disappear.  If  the  treatment  is  persisted  in,  and  every  measure 
taken  to  improve  the  local  condition,  to  provide  for  local  blood-supply,  and 
to  raise  the  antibacterial  power  of  the  blood  by  vaccine,  nearly  all  cases 
should  be  improved  and  all  but  a  few  cured. 

Bc^ema. — Eczema  will  often  be  found  associated  with  the  presence 
of  staphylococcus  in  the  skin,  either  as  a  cause  or  as  a  secondary  invader. 
In  either  case,  appropriate  vaccine  treatment  is  indicated.  Chronic 
eczema  in  cases  of  long-standing  furunculosis  have  done  extremely  well 
under  treatment  by  autogenous  vaccines.  The  locations  of  the  lesions 
have  beejn  indifferently  in  the  axilla,  sides  of  the  neck,  groins,  and  flexures 
of  the  knees  and  elbows,  situations  where  irritation  or  increased  bodily 
heat  and  skin  moisture  have  induced  a  condition  of  lessened  resistance 
to  bacterial  growth.  In  eight  well-marked  cases  of  spreading  eczema  of 
long  standing,  after  a  treatment  varying  from  three  weeks  to  two  months, 
a  cure  resulted  which,  in  each  case,  so  far  as  the  writer  knows,  has  been 
permanent. 

Varicose  "B^czetna. — This  condition  is  dependent,  to  a  large  degree, 

on  an  infection  of  skin  in  a  position  where  the  resistance  to  bacterial 

growth  has  been  lowered  by  long-standing  chronic  passive  congestion. 

'Staphylococcus  is  commonly  present.     The  lesion  ordinarily  starts  as 


730  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

a  small  point,  particularly  on  the  leg,  and  tends  to  spread  over  a  con- 
siderable area,  causing  swelling,  redness,  tenderness,  desquamation, 
and  occasionally  spots  where  the  skin  breaks  down  and  watery  or  puru- 
lent discharge  takes  place — the  so-called  varicose  ulcer.  Vaccine  treat- 
ment in  these  cases  is  apt  to  be  of  only  temporary  avail  if  the  patient 
persists  in  walking  about.  If  the  leg  can  be  kept  horizontal,  and  slightly 
antiseptic  ointments  applied  as  indicated,  a  suitable  staphylococcic 
vaccine  injected  in  doses  from  100,000,000  at  first  to  400,000,000  to 
500,000,000  later,  every  five  or  six  days,  there  should  be  uniform  im- 
provement, and  in  some  cases  the  result  will  be  striking.  The  condition 
is  prone  to  recur,  however,  as  the  patient  vralks  about  again.  As  soon 
as  the  lesions  have  healed,  the  leg  should  be  kept  fairly  tightly  bandaged 
in  order  to  prevent  swelling.- 

We  must  not  expect  too  much  from  the  vaccine  in  these  cases,  because 
infection  is  often  subsidiary,  the  bacteria  growing  simply  because  proper 
culture-medium  is  furnished,  and  because  the  condition  which  favors 
bacterial  growth  cannot  always  be  satisfactorily  remedied.  As  is 
well  known,  the  results  of  the  treatment  in  this  type  of  eczema  by  the 
usual  measures  are  extremely  unsatisfactory.  The  use  of  vaccines 
seems  to  cause  temporary  improvement,  and  under  favorable  conditions 
may  result  in  a  lasting  cure.  The  immediate  control  of  this  trouble- 
some condition  is  commonly  so  definite  that  the  advantage  of  the  use 
of  vaccines  in  association  with  other  reasonable  measures  is  at  once 
appreciated.  It  will  be  found  best  always  to  use  an  autogenous  vaccine, 
but  until  this  can  be  prepared,  a  stock  vaccine,  consisting  of  aureus  and 
albus,  should  be  used. 

Varicose  Ulcer. — Varicose  ulcers  are  most  commonly  infected  by 
staphylococcus,  although  other  organisms  may  be  found.  If  the  condi- 
tions indicate  infection,  cultures  should  always  be  taken  and  the  organ- 
ism determined.  If  staphylococcic  vaccine  is  used,  the  dosage  should 
be  carried  on  as  usual  in  localized  infections,  and  may  be  increased  as 
the  treatment  progresses.  In  several  cases  treated  by  the  writer  a  stock 
vaccine  was  used  to  advantage.  The  inflammatory  condition  about  the 
ulcer  cleared  up  after  two  or  three  inoculations,  and  the  tendency  to 
close  in  became  immediately  evident.  The  ulcer  was  washed  several 
times  a  day  with  Wright's  citrate  and  salt  solution,  in  order  to  promote 
free  discharge  and  bring  as  much  serum  as  possible  to  the  part.  When 
this  solution  irritates  and  causes  pain,  it  is  necessary  to  dilute  it  one 
half;  that  is,  ^  per  cent,  sodium  citrate  and  2  per  cent,  sodium  chlorid. 
Infection,  of  course,  is  only  one  factor  in  these  cases,  and  unless  other 
conditions  are  properly  met,  recurrence  is  likely. 


LOCALIZED    TUBERCULOSIS 


731 


LOCALIZED  TUBERCULOSIS 

Diagnosis. — Before  specific  treatment  by  tuberculin  is  applied  in 
any  case,  clinical  diagnosis  should  be,  if  possible,  supplemented  by  exact 
laboratory  diagnosis  or  by  means  of  certain  tuberculin  tests.  In  the 
case  of  nodes  especially,  it  is  impossible  to  say,  from  clinical  appearance 
and  conditions,  that  the  etiology  is  definitely  tuberculous.  In  the  ques- 
tion of  tuberculosis  of  the  genito-urinary  tract,  the  absence  of  bacilli  in 
microscopic  examination  of  the  sediment  should  lead  one  to  further 
effort  for  diagnosis  by  inoculation  of  guinea-pigs.  The  diagnosis  of 
cystitis  or  pyelitis  is  frequently  made  as  being  due  to  the  colon  bacillus, 
because  of  its  presence  in  the  urine  in  large  numbers.  In  these  cases 
tuberculosis  should  always  be  suspected  arid  guinea-pigs  inoculated. 
Where  it  is  possible  to  obtain  pus,  such  specimens  should  likewise  be 
injected  into  animals  if  no  bacilli  are  found  in  smears.  In  the  case  of 
fistula  or  sinus,  scrapings  from  the  wall  or  bits  of  tissue  should  be  ex- 
amined histologically.  Where  there  is  extensive  involvement  of  nodes 
of  the  neck  without  suppuration,  and  operative  procedures  on  account 
of  the  extent  of  involvement  may  not  be  deemed  wise,  a  small  portion  of 
a  single  node  may  be  excised  for  the  purpose  of  diagnosis.  In  the  case 
of  closed  infection,  where  it  is  impossible  to  obtain  discharge  or  a  specimen 
of  the  organ  infected  for  histologic  examination,  some  of  the  newer 
methods,  such  as  von  Pirquet's  tuberculocutaneous  test,  the  eye  reaction 
of  Calmette  and  Wolf-Eisner,  and  diagnosis  by  means  of  variations  of 
the  opsonic  index  following  induced  autoinoculation,  may  be  used. 

There  is  no  method  at  the  present  time  which  can  be  consistently 
applied  in  practice  to  determine  the  question  of  whether  infection  is  due 
to  bovine  or  human  bacillus,  unless  the  organism  can  be  isolated  and 
grown.  In  the  majority  of  cases  of  localized  tuberculosis  favorable 
results  will  be  obtained  upon  the  exhibition  of  human  tuberculin  B.  E. 
or  T.  R.  Considering  the  fact  that  certain  case's  may  be  of  bovine 
origin,  that  many  may  be  infected  with  both  types,  the  use  of  a  tuberculin 
composed  of  equal  parts  of  human  and  bovine  bacilli  may  be  advantage- 
ous. Allen^  states  that  results  in  the  use  of  vaccine  prepared  in  this 
manner  have  appeared  to  be  so  markedly  superior  to  any  he  had  previ- 
ously obtained  that  the  use  of  the  ordinary  T.  R.  had  been  entirely  given 
up  in  favor  of  this  mixture.  The  series  of  cases  he  has  treated,  he 
states,  is  too  small  to  enable  him  to  state  definitely  as  to  the  value  of 
this  mixed  vaccine.  Where  it  is  possible  to  isolate  the  organism,  it  has 
been  suggested  by  a  number  of  writers  that  an  autogenous  vaccine 
would  be  decidedly  advisable,  but  there  are  no  statistics  at  present  as 

^  \'accine  Therapy  and  Opsonic  Treatment,  1008,  p.  1 16. 


732  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

to  the  results  in  treatment.  Given  a  diagnosis  of  tuberculosis  by  any 
of  the  methods  above  used,  it  is  generally  the  custom  to  use,  as  treatment, 
human  tuberculin  as  a  therapeutic  measure. 

Professor  Calmette  ^  vt^rites  as  follows  as  to  the  diagnosis  of  tubercu- 
losis: That  we  should  choose  those  methods  which,  without  injuring  the 
patient,  are  capable  of  supplying  the  most  exact  information.  He 
advises  against  the  employment  of  subcutaneous  injections  of  tuberculin, 
because  (i)  the  general  febrile  reaction  produced  is  accompanied  generally 
by  a  local  congested  reaction  about  the  tuberculous  foci,  which  commonly 
results  in  a  dangerous  diffusion  of  the  bacilli;  (2)  tuberculin  injections 
can  never  be  utilized  among  febrile  patients;  (3)  where  there  is  aggrava- 
tion of  the  disease  following  tuberculin  used  diagnostically,  it  may  be 
attributed,  rightly  or  wrongly,  to  the  injection  of  the  tuberculin.  The 
inconvenience  and  danger  of  this  method  restrict  it  to  the  exceptional 
circumstances  in  which  the  local  tuberculin  reaction  has  not  furnished 
sufficient  information. 

The  von  Pirquet  Cutaneous  Reaction. — If  positive,  he  states,  we  may 
conclude  that  the  patient  is  the  bearer  of  old  or  new  tuberculous  lesions.  The 
fact  that  it  is  present  where  the  lesion  is  latent  or  old,  calcified,  or  fibrous, 
which  appears  to  be  quite  cured,  would  render  it  insufficient  as  a  diagnostic  test 
on  which  to  base  treatment.  This  is  because,  in  a  series  of  statistics  recently 
published,  55  in  every  100  adults  showed  a  positive  reaction.  In  children 
under  three  years  of  age,  apparently  healthy,  there  were  but  4  positive  reac- 
tions per  100.  In  the  presence,  then,  of  a  suspicious  lesion  in  a  child  under 
three,  the  presence  of  the  reaction  would  be  confirmatory  of  the  tuberculous 
nature  of  the  disease,  whereas  in  adults  there  would  be  no  such  confirmation. 

Among  adults  and  children  over  three,  if  the  cutaneous  reaction  is  positive, 
he  advises  the  use  of  the  reaction  of  Wolf-Eisner-Calmette,  since  it  discloses 
with  more  precision  the  existence  of  tuberculous  lesions.  This  reaction  in- 
dicates to  some  extent  the  degree  of  infection,  because  it  is  clear  and  more  intense 
when  the  infection  is  recent.  It  means  a  focus  incompletely  cured,  with  living 
bacilli  present.  Where  lesions  have  been  caseous  for  a  long  time,  or  are  very 
extensive  or  virulent,  as  miliary  tuberculosis,  meningitis,  or  peritonitis,  the 
reaction  may  appear  late  or  fail,  and  is  almost  always  negative  in  old,  cachectic, 
tuberculous  patients.  Among  patients  apparently  healthy,  it  is  positive  in 
about  18  per  cent,  of  the  cases.  This  proportion  indicates  the  average  number 
of  latent  cases  that  are  clinically  not  revealed. 

Based  on  20,000  or  more  observations  among  clinically  tuberculous  patients, 

the  conjunctival  reaction  is  positive  in  92  per  cent.     The  positive  reaction  points 

to  an  almost  certain  existence  of  a  bacillary  focus  of  varying  extent  and  gravity 

and  is  a  valuable  warning.     The  absence  of  the  reaction  does  not  allow  us  to 

^  Brit.  Med.  Jour.,  August  28,  1909. 


VON  pirquet's  reaction  733 

determine  the  absence  of  lesions.  He  does  not  agree  with  Wolf-Eisner  that 
prognostic  indications  may  be  obtained  from  the  reaction,  because  in  some 
patients  production  of  antibodies  which  control  the  intensity  of  the  reaction 
is  in  no  wise  in  relation  to  the  gravity  of  the  disease.  It  seems  certain  that 
when  it  becomes  negative  in  patients  who  formerly  reacted  positively,  and 
when,  at  the  same  time,  no  clinical  symptoms  have  developed,  it  permits  us 
to  determine  the  anatomic  cure  of  tubercles. 

Among  children  over  three  and  adults,  the  conjunctival  reaction  gives 
us  much  more  accurate  information  than  von  Pirquet's  reaction  as  to  the 
presence  or  absence  of  active  foci.  In  febrile  cases  it  is  the  only  one  that  can 
be  employed  without  inconvenience  and  danger. 

The  Techliique  of  the  Ophthalmic  Reaction. — The  eye  should  be 
inspected  to  ascertain  if  it  is  perfectly  sound.  It  should  be  irrigated 
wdth  2  per  cent,  boric-acid  solution,  then  two  or  three  drops  of  a 
sterile  i  or  2  per  cent,  solution  of  old  tuberculin  introduced. 

Precautions  and  Dangers  in  the  Application  of  the  Eye  Reaction. — The 
eye  must  be  in  good  condition,  the  tuberculin  sterile  and  pure;  the  patient 
must  keep  his  fingers  out  of  his  eyes. 

Untoward  Results. — Calmette  mentions  20,000  observations,  in 
which  he  found  but  80  relating  to  the  production  of  ulcerative  keratitis 
or  serious  conjunctivitis  attributable  to  this  test. 

Delayed  Reaction. — If,  when  there  is  no  reaction  at  first,  it  develops 
some  days  later,  Calmette  believes  that  such  patients  are  bearers  of 
tuberculous  lesions,  though  perhaps  very  minute;  that  proof  of  this 
can  be  furnished  by  subcutaneous  injection  and  noting  resulting  thermic 
reaction. 

In  tuberculous  patients  the  reaction  becomes  more  intense  sometimes 
when  repeated. 

Where  neither  the  conjunctival  nor  the  von  Pirquet  reaction  appears, 
it  may  be  necessary,  if  diagnosis  is  important,  to  use  the  inoculation 
method. , 

Von  Pirquet's  Tuberculocutaneous  Reaction. — Technique. — The 
ventral  surface  of  the  forearm  is  sterilized,  dried,  and  tv\^o  minute 
drops  of  pure  old  tuberculin  are  placed  three  inches  apart.  The  point 
of  a  sterile  scalpel  is  then  rotated,  using  slight  pressure,  in  such  a  manner 
as  to  introduce  some  of  the  tuberculin  into  the  skin.  The  knife  may  be 
rotated  perhaps  one-half  dozen  times.  The  excess  of  tuberculin  is 
wiped  off  after  fi\'e  minutes.  The  patient  is  told  to  report  in  twenty-four 
hours.  A  positive  reaction  may  be  described  as  anything  betAveen  a 
small,  dull-red  papule,  perhaps  |  in.  in  diameter,  to  an  inflamed  papule, 
J  in.  in  diameter,  with  a  red  areola,  and  swollen.    After  two  or  three  days, 


734  THERAPEUTIC   IMMUNIZATION   AND    VACCINE    THERAPY 

in  case  of  the  severe  reaction,  the  superficial  layers  of  skin  may  become 
necrotic  and  whitened,  and  in  this  type  there  may  persist  for  some 
months  a  brownish  discoloration.  In  the  ^vriter's  experience,  the  dull 
reactions  unassociated  with  areola  have  been  associated  with  tuberculous 
conditions  of  considerable  previous  duration,  and  the  more  brilliant 
reactions  with  the  earlier  processes.  The  points  of  inoculation  need 
not  be  protected.  I  have  never  seen  any  untoward  happenings  following 
this  method  of  diagnosis. 

The  interpretation  of  the  different  degrees  of  the  von  Pirquet  skin 
reaction,  as  to  the  sort  of  lesion  with  which  they  are  consistent,  is  more 
or  less  uncertain.  The  writer  has,  during  the  past  two  years,  used  the 
test  in  several  hundred  cases.  In  the  last  stages  of  pulmonary  tuber- 
culosis it  has  been  in  some  cases  either  very  slight  or  absent.  In  early 
pulmonary  tuberculosis  it  has  been  commonly  very  intense.  In  active 
tuberculosis  elsewhere  it  has  been  also  quite  intense.  In  localized  lesions 
of  long  standing  the  reaction  is  commonly  slight,  dull  in  color,  and  the 
papule  of  small  dimensions  and  without  areola. 

In  the  case  of  an  otherwise  healthy  individual,  the  development  of 
an  acute  adenitis  associated  with  a  negative  skin  reaction,  or  one  of 
very  slight  degree,  is  strongly  suggestive  that  the  lesion  is  non-tuberculous. 
If  the  reaction  be  brilliant,  in  the  absence  of  any  demonstrable  focus 
elsewhere,  the  lesion  may  be  considered  to  be  presumably  tuberculous. 
It  has  been  shown  that  55  in  100  healthy  adults  give  a  positive  reac- 
tion. In  healthy  children  under  three  years  there  were  reported  but 
4  positive  reactions  per  100.  Given,  therefore,  a  suspicious  lesion  in 
a  child  under  three,  the  positive  reaction  would  furnish  confirmatory 
evidence  of  the  tubercular  nature  of  the  process.  In  adults  a  positive 
reaction  would  by  no  means  be  so  confirmatory.  In  the  case  of  glands 
of  long  duration,  a  dull  reaction  would  be  consistent  with  a  tuberculous 
nature.  The  same  may  be  said  of  joints  and  bone  disease  of  long 
standing.  Cases  of  healed  pulmonary  tuberculosis  commonly  react 
with  very  slight  intensity.  Fresh  tuberculous  glands  developing  in  these 
apparently  arrested  pulmonary  cases  has  been,  in  the  writer's  experience, 
associated  with  an  intense  reaction. 

It  would  appear  that  the  ophthalmic  reaction  is  being  generally  given 
up  in  favor  of  the  reaction  of  von  Pirquet.  It  is  not  at  all  certain  that 
the  former  furnishes  any  more  information  than  the  latter.  The  skin 
reaction  certainly  has  in  its  application  no  element  of  danger.  This 
cannot  be  said  of  the  eye  reaction. 

Given  a  clinical  diagnosis  of  tuberculosis,  and  a  skin  reaction  consist- 
ent in  its  character  to  that  which  would  be  expected  to  accompany  the 


DIAGNOSIS    OF   TUBERCULOSIS   BY   OPSONIC    INDEX  735 

lesion,  we  are  justified  in  the  use  of  tuberculin  as  a  therapeutic  measure 
if  other  methods  of  diagnosis  are  contraindicated  or  not  decisive. 

If  more  accurate  diagnosis  is  required,  some  one  of  the  inoculation 
methods  may  be  used.  If  the  question  is  one  of  pulmonary  tuberculosis, 
and  the  temperature  is  normal,  an  injection  of  ^^q-  mg.  or  more  of  old 
tuberculin  will  commonly  produce  elevation  in  temperature,  a  few 
hours  after  inoculation,  and  increase  in  the  number  of  rales  to  be  heard 
in  the  lungs,  if  the  case  is  one  of  tuberculosis.  In  localized  tuberculosis 
the  same  focal  reaction  in  a  gland,  in  a  joint,  or  elsewhere  in  the  soft 
tissues  may  be  obtained  and  manifested  by  swelling,  tenderness,  local 
pain,  and  discomfort  if  the  infection  is  tuberculous.  The  dosage  in  an 
adult  which  might  be  expected  to  produce  such  a  focal  reaction  should 
be  from  yoVo"  ^°  5^0"  "^8-  tuberculin  B.  E.  or  T.  R.  The  reaction  ob- 
tained is  comparable  to  that  obtained  in  the  lung  from  the  injection  of 
old  tuberculin.  In  many  cases  of  localized  tuberculosis,  even  though 
large  doses  are  given,  no  focal  reaction  is  obtained. 

Diagnosis  by  the  Opsonic  Indes. — Inoculation  Method. — If  a  dose 
of  YoYo"  ^'S-  o^  tuberculin  B.  E.  be  inoculated  into  a  patient  uninfected 
by  tubercle,  and  opsonic  determinations  be  made  immediately  after 
inoculation  and  two,  four,  and  six  hours  later,  no  negative  phase  of  any 
moment  will  be  observed.  In  the  case  of  the  tuberculous  individual, 
however,  a  negative  phase  will  probably  be  induced  during  the  first  few 
hours  after  inoculation.  A  drop  in  the  opsonic  index  from  1.20,  for 
instance,  to  0.80  would  be  suggestive,  and  if  repeated,  would  be  con- 
clusive. If  the  opsonic  index  is  low  at  the  start,  inoculation  may  be 
followed  by  a  sudden  sharp  rise  and  later  a  fall.  Such  fluctuations  do 
not  occur  in  uninfected  individuals  and  are  diagnostic  if  the  opsonic 
indices  are  obtained  accurately.  The  difficulty  of  this  method  is  that 
it  does  not  localize. 

In  localized  tuberculosis  without  fever  the  vast  majority  of  cases 
>show  a  low  opsonic  index.  One  index  determination  is  not  sufficient, 
however,  but  if  several  low  indices  are  obtained  at  different  times,  or  if 
the  index  shows  wide  fluctuations,  we  may  presume  that  we  are  dealing 
with  tuberculosis.  We  have  here  also  the  necessity  of  localization, 
and  we  do  not  obtain  any  more  information  actually  than  the  von  Pirquet 
skin  reaction  gives  us.  . 

Diagnosis  by  Induced  Autoinoculation. — When  a  focus  of  infec- 
tion, whatever  it  be,  is  stirred  up  by  massage  or  passive  motion,  or  if 
the  blood,  by  active  or  passive  hyperemia,  be  forced  into  the  lesion  in 
increased  amount,  we  have  variations  in  the  opsonic  index  which  indicate 
that  we  are  dealing  with  a  protective  response  against  the  organism  to 


736  THERAPEUTIC   IMMUNIZATION   AND   VACCINE   THERAPY 

which  the  index  varies.  We  must,  therefore,  have  produced  auto- 
inoculation  by  these  measures.  In  the  case  of  an  infection  in  some 
portion  of  the  body  to  which  Bier's  passive  hyperemia  can  be  apphed,  a 
method  of  diagnosis  is  as  follows:  Bier's  bandage  is  applied  for  one-half 
hour,  for  instance,  in  the  case  of  a  wrist-  or  knee-joint,  blood  specimens 
are  taken  before,  immediately  after,  one-half  hour  after,  and  two  hours, 
four  hours,  and  eight  hours  subsequently,  and  once  or  twice  on  the  follow- 
ing day.  These  specimens  are  collected  and  kept  in  an  ice-box  until  the 
last  one  is  taken,  and  then  the  opsonic  indices  against  the  tubercle  and 
other  organisms  suspected  are  determined,  in  the  case  of  each  specimen 
of  blood.  If  the  indices  show  variation  from  normal  to  one  of  these 
organisms  and  not  to  the  other,  the  diagnosis  in  favor  of  the  former  may 
be  conclusively  made.  If  the  index  is  low  at  the  start,  there  will  ordinarily 
be  a  brief  rise  and  then  a  subsequent  fall,  accentuated  and  prolonged 
according  as  the  autoinoculation  is  large  or  small.  If  small,  there  may 
be  an  immediate  rise.  If  the  index  is  elevated  above  normal  at  the  time, 
there  will  be  ordinarily  an  immediate  drop  in  the  first  few  hours,  followed 
by  a  subsequent  rise  If  the  technique  is  in  the  hands  of  an  experienced 
worker,  the  information  obtained  is  accurate,  and  this  diagnostic  test 
will  be  found  to  be  one  of  the  most  delicate  and  accurate  that  can  be 
applied.  Where  the  lesion  is  in  a  joint,  instead  of  the  use  of  Bier's 
bandage,  the  patient  may  be  made  to  stir  up  the  focus  of  infection  by 
walking  or  by  active  or  passive  motion.  If  the  infection  is  in  the  soft 
tissues,  such  as  glands,  kneading  or  hot  applications  may  produce  the 
same  autoinoculating  effect.  In  questions  of  tuberculous  peritonitis, 
the  abdomen  may  be  deeply  kneaded  in  order  to  induce  autoinoculation. 
If  a  focus  is  suspected  in  the  lung,  active  exercise  for  half  an  hour  im- 
mediately on  arising  may  induce  the  required  autoinoculation.^  It  is 
realized  that  these  methods  involving  the  use  of  the  opsonic  index  have 
a  limited  application,  but  this  is  on  account  of  the  fact  that  laboratory 
workers  are  few  who  have  the  time  and  the  patience  to  undertake  such 
delicate  methods  of  serum  diagnosis.  To  be  diagnostic,  the  variation  in 
the  opsonic  indices  should  be  at  least  0,30. 

The  advantage  of  this  method  of  diagnosis  over  all  the  others,  when 
it  can  be  successfully  applied,  is  that  it  not  only  shows  that  there  is 
tuberculosis  somewhere  in  the  body,  but  give  e^'idence  that  the  part 
which  has  been  manipulated  is  the  actual  focus  of  disease.  Its  further 
advantage  lies  in  its  harmlessness.  The  difficulty  of  obtaining  accurate 
opsonic  index  determination  limits  its  usefulness  in  practice  as  a 
procedure  for  general  use. 

^  Inman,  Lancet,  January  25,  1908. 


METHODS   OF    GIVING   TUBERCULIN  73/ 

Choice  of  Tuberculin. — In  the  treatment  of  localized  tuberculosis, 
we  are  commonly  not  dealing  with  a  general  condition  of  toxemia, 
because  there  is  an  absence  of  autoinoculation.  It  would  seem,  there- 
fore, that  we  desire,  above  all,  to  produce  an  antibacterial  immunity. 
We  should,  therefore,  choose  a  tuberculin  composed  of  bacterial  sub- 
stance. The  bacillus  emulsion,  being  composed  of  bacterial  substance 
from  which  nothing  has  been  extracted,  would  appear  to  offer  all  the 
effective  stimulus  which  the  bacteria  are  capable  of  affording.  Tuber- 
culin R.  may  be  used  with  good  results,  but  it  has  not,  in  the  writer's 
hands,  been  as  efficient  as  the  bacillus  emulsion  (Tuberculin  B.  E.). 

Methods  of  Giving-  Tuberculin. — Clinical  Method. — Tuberculin 
is  given,  according  to  this  method,  with  the  idea  of  securing  tolerance  to 
very  large  doses.  It  takes  for  its  guidance  the  production  of  toxic  symp- 
toms. When  marked  local  or  general  reactions  are  produced,  the  dosage 
is  considered  to  be  too  large,  and  the  subsequent  injection  is  always  of  a 
smaller  amount.  Amount  of  dosage  is  again  gradually  increased  until 
toxic  symptoms  are  again  produced  or  the  patient  recovers.  The  increase 
in  dosage  is,  of  course,  gradual,  but,  inasmuch  as  symptoms  of  intoler- 
ance are  taken  as  an  indication  that  the  maximum  dose  has  temporarily 
been  reached,  it  would  seem  that  production  of  toxic  symptoms  must 
be  a  common  occurrence.  We  know  that,  associated  with  a  condition 
of  toxemia  produced- by  an  excessive  dose  of  tuberculin,  there  is  a  con- 
dition of  lowered  antibacterial  power  of  the  blood-stream  or  a  negative 
phase.  We  suspect,  even  in  localized  tuberculosis,  associated  with 
symptoms  of  toxemia,  that  living  bacteria  are  actually  being  taken  into 
the  blood-stream,  which  fact,  taken  in  connection  with  its  low  anti- 
bacterial power,  may  conceivably  be  a  menace  to  the  patient,  in  rendering 
the  development  of  other  foci  of  infection  possible. 

It  appears  to  be  a  fact  that  tuberculin  may  be  given  by  the  clinical 
method  with  more  rapid  improvement  and  cure  than  when  the  opsonic 
method  is  used.  Sufficient  numbers  of  cases  have  not  been  reported  to 
determine  whether  or  not  the  general  or  focal  reaction  produced  by 
large  doses  may  be  dangerous  to  the  patient  in  the  case  of  localized 
tuberculosis. 

The  Opsonic  Method. — The  opsonic  method  of  giving  tuberculin 
has  been  previously  discussed.  The  rationale  of  the  method  in  giving 
tuberculin  is  based  on  the  fact  of  correlation  that  has  been  found  to  exist 
between  a  high  opsonic  power  and  the  amelioration  of  local  and  general 
symptoms;  on  the  fact  that  recovery  from  infectious  disease  is  preceded 
or  accompanied,  with  rare  exception,  by  an  elevated  opsonic  power;  that, 
on  the  other  hand,  associated  with  a  negative  phase,  there  have  been  found 

47 


738  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

generally  to  exist  conditions  of  chronicity,  local  or  general  symptoms, 
which  indicate  that  the  resistance  to  the  infecting  bacteria  is  correspond- 
ingly low;  further,  on  the  fact  that  inoculation  of  appropriate  vaccine 
in  proper  dosage  artificially  elevates  the  opsonic  power,  and  if  the 
dosage  is  repeated  at  proper  intervals,  a  more  or  less  continuously 
elevated  opsonic  power  may  be  produced;  that,  in  association  with  this 
increase  in  the  ability  of  the  phagocytic  response,  a  condition  of  im- 
provement supervenes  which,  if  maintained,  may  end  in  final  cure.  It 
recognizes  that  the  import  of  the  toxic  symptoms  that  may  follow  the 
injection  of  tuberculin  in  doses  of  sufficient  size,  namely,  that  resistance 
to  the  tubercle  bacillus  has  been  temporarily  lowered;  in  the  low  opsonic 
index  correlated  with  this  unfavorable  condition  it  recognizes  a  condi- 
tion to  be  avoided.  Based  on  these  considerations,  the  aim  of  Wright's 
method  is  to  arrive  at  a  dosage  which  shall  induce  a  brief  period  of 
lowered  resistance,  negative  phase  or  period  when  subjective  symptoms 
may  develop,  this  to  be  followed  by  a  period  of  increased  resistance, 
associated  with  elevated  opsonic  power,  lasting  for  several  days  if  pos- 
sible. The  indication  for  the  subsequent  dose  is  the  fall  of  the  opsonic 
power  to  or  below  normal.  Maximum  immunizing  responses  are  thus 
obtained  repeatedly.  After  several  doses  have  been  given  of  the  same 
size,  the  opsonic  power  neither  rises  so  high,  nor  remains  elevated  so  long 
a  time,  as  resulted  from  the  first  dose  given.  The  period  of  negative 
phase  also  becomes  shorter.  When  the  opsonic  index  shows  this  to 
be  the  case,  larger  doses  are  gi\'en.  Thus  immunizing  response  is 
obtained  with  avoidance  of  subjecti\'e  symptoms  after  dosage.  The 
results  of  this  method,  using  the  opsonic  index  as  a  guide,  appear  to 
be  consistently  good  in  producing  improvemient  and  cure,  as  will  be 
shown  later. 

The  use  that  Wright  has  made  of  the  opsonic  index  in  studying  the 
bodily  reaction  against  infection  has  formed  a  basis  for  the  rational 
application  of  specific  immunization  methods.  One  of  the  most  im- 
portant conceptions  that  Wright  has  given  us  is  that  efficient  immunizing 
response  to  minute  doses  of  tuberculin  can  be  achieved,  and  that  when 
tuberculin  is  given  in  such  a  manner  as  to  secure  a  sequence  of  such 
immunizing  responses,  clinical  improvement  and  cure  commonly  result, 
without  the  usual  toxic  symptoms  that  have  hitherto  characterized 
attempts  at  immunization  with  tuberculin. 

The  treatment  of  large  numbers  of  cases  under  guidance  of  the 
opsonic  index  has  furnished  a  scheme  of  treatment  that  can  be  followed 
without  the  need  of  the  opsonic  index,  and  with  approximately  the  same 
end  accomplishment.     Such  a  scheme  differs  from  the  clinical  method 


TUBERCULOUS   LYMPHNODITIS  739 

of  giving  tuberculin  in  that  it  does  not  seek  tolerance  of  large  doses, 
but  rather  a  succession  of  immunizing  responses;  it  never  reaches  a 
dose  of  toxic  proportions  except  by  error,  and  it  attempts  to  carry  out 
the  treatment  from  beginning  to  end  without  the  production  of  toxic 
symptoms.  Such  a  method  is  certainly  the  most  conservative  that  could 
be  used.  It  is  to  be  commended  as  against  any  method  that  takes  for  its 
guide  to  dosage  intolerance,  as  indicated  by  local  or  general  toxic  reaction 
following  inoculation. 

In  practice,  it  means  that  the  initial  dose  of  tuberculin  is  alv\ays 
minute  enough  not  to  produce  any  symptoms;  that  the  increase  in  dose 
is  so  gradual  that  any  symptoms  which  might  be  associated  with  negative 
phase  are  avoided. 

During  the  past  two  years  the  writer  has  treated  over  100  cases  of 
localized  tuberculosis  without  the  use  of  the  opsonic  index  as  a  guide. 
The  dosage  has  been  increased  as  nearly  as  possible  in  the  manner 
that  Wright  has  used  when  guided  with  the  opsonic  index.  The  pro- 
duction of  anything  suggestive  of  toxic  symptoms  after  inoculation  with 
tuberculin  has  been  almost  entirely  absent. 

I/Ocal  Measures  Calculated  to  Render  the  Immunising 
Response  Efficient. — A  condition  of  restricted  blood-supply  often- 
times renders  the  inoculation  treatment  of  tuberculosis  inefficient,  because, 
no  matter  how  much  elevated  the  opsonic  power  of  the  blood  becomes 
following  inoculation,  the  new  antibacterial  substances  can  obviously 
only  become  effective  in  the  lesion  when  the  blood-supply  is  unobstructed. 
It  is,  therefore,  quite  as  important  in  such  cases  to  use  measures  to  in- 
crease the  local  blood-supply  in  the  focus  of  infection  as  it  is  to  raise 
the  antibacterial  power  of  the  blood-stream  itself.  The  majority  of 
cases  of  localized  tuberculosis  do  not  require  the  application  of  local 
measures,  but,  the  absence  of  improvement  after  several  months  of 
treatment  with  tuberculin  would  suggest  that  measures  must  be  taken 
to  cause  -determination  of  blood  actively  to  the  focus;  application 
of  heat,  of  Bier's  suction,  and,  if  the  location  of  the  lesions  makes  it 
applicable,  the  guarded  use  of  Bier's  passive  hyperemia  by  means  of 
bandage. 

Tuberculous  I/ymphnoditis. — Before  treatment  is  started,  care- 
ful physical  examination  should  be  made,  in  order  to  determine  if  there 
are  other  lesions  which  would  lead  one  to  modify  the  dosage  of  tuberculin. 
If  there  is  an  active  pulmonary  lesion,  associated  with  temperature,  the 
treatment  should  be  directed  toward  the  cure  of  this  condition  and  the 
node  temporarily  neglected.  If  there  is  a  tuberculous  lesion  found  else- 
where, as,  for  instance,  in  the  eye,  in  the  bladder,  testicle,  etc.,  if  the 


740  THERAPEUTIC    IMMUNIZATION    AND    VACCINE   THERAPY 

tuberculin  be  given  according  to  the  principles  of  Wright,  treatment  need 
not  be  modified  or  the  dosage  lessened  on  account  of  these  conditions. 

Surgical  Indications. — In  the  case  of  a  single  encapsulated  node 
without  surrounding  induration,  in  a  locality  where  the  scar  resulting 
from  operation  would  r^ot  matter,  the  quickest  and  best  procedure  would 
be  to  excise.  If  the  same  sort  of  node  has  been  existant  for  a  long  time, 
and  if  the  condition  suggests  that  it  be  caseated,  excision  would  always 
be  the  best  treatment.  The  :x:-ray  will  often  furnish  e\ddence,  if  the  node 
is  favorably  situated,  as  to  whether  or  not  caseation  or  calcification  has 
taken  place.  It  is  obvious  that  against  caseated  and  calcified  nodes 
tuberculin  can  accomplish  nothing.  If  the  glands  are  very  extensive, 
and  still  seem  to  offer  assurance  that  extirpation,  more  or  less  complete, 
may  be  obtained,  surgical  measures  would  again  seem  to  be  indicated, 
inasmuch  as  tuberculin,  if  used  postoperatively,  is  usually  efficient  in 
preventing  extensive  recurrence,  even  if  all  the  infected  tissue  is  not 
removfed.  When  liquefaction  has  taken  place,  the  pus  should  be  drained. 
Drainage  should  be  put  off,  if  tuberculin  is  used,  until  as  much  of  the 
node  as  is  possible  has  been  liquefied,  in  order  that  the  problem,  for 
tuberculin  may  be  less.  We,  therefore,  should  postpone  incision  until 
the  skin  shows  evidence  of  thinning  out  and  spontaneous  rupture.  In 
most  conditions  of  this  kind  incision  is  quite  unnecessary,  and,  if  used 
at  all,  should  be  more  of  a  puncture  than  an  incision,  as  it  is,  with  a  small 
opening,  much  easier  to  prevent  secondary  infection  than  if  a  wide  incision 
were  made.  Quite  as  satisfactory  as  incision,  however,  is  puncture  with 
a  large  aspirating  needle  and  removal  of  pus  by  aspiration.  In  this 
way  the  pus  is  removed  and  the  resulting  scar  is  minute.  Aspiration 
may  be  necessary  repeatedly,  but  is  ordinarily  efficient.  The  resulting 
scar  is  in  the  form  of  a  depression  or  dimple,  which  gradually  smooths 
out  and  becomes  less  noticeable. 

This  leaves  for  tuberculin,  then,  cases  of  node  involvement  which  are 
obviously  too  extensive  in  which  to  expect  complete  extirpation;  in 
which  the  resulting  scar  would  be  undesirable;  in  which  the  nodes  are 
too  scattered  to  render  anything  but  several  incisions  sufficient;  for  the 
after-treatment  of  cases  where  the  attempt  has  been  made  completely  to 
extirpate,  partly  to  extirpate;  and  for  those  in  which  there  has  already 
been  recurrence  beneath  the  skin,  or  in  which  there  is  a  chronic  dis- 
charging sinus.  Based  on  statistics  of  results  in  these  glandular  cases 
which  are  available,  the  surgeon  may  do  much  less  extensive  operation, 
and  at  the  same  time  feel  reasonably  sure,  if  after  treatment  with  tuber- 
culin is  conscientiously  carried  out,  that,  even  though  small  nodes  have 
been  missed,  the  average  ultimate  results  in  the  cases  ^^  ill  be  much  bet- 


THE    ROLE    OF    TUBERCULIN  74I 

ter  than  in  the  past  when  attempts  have  been  made  to  complete  extirpa- 
tion, and  it  has  not  been  achieved  on  account  of  extensive  involvement. 
At  the  same  time,  in  the  majority  of  cases,  the  surgeon  may  limit  him- 
self to  the  excision  of  the  most  prominent  masses  if  this  be  deemed 
expedient,  and  trust  to  the  efficacy  of  tuberculin  to  complete  the  cure. 

The  R61e  of  Tuberculin. — The  tuberculous  lymph-node  is,  as  a 
rule,  so  well  walled  off  from  the  circulating  blood  that  febrile  conditions 
are  uncommon.  We  may  conclude  that,  as  a  result  of  this  walling  off,  the 
blood  does  not  take  up  in  any  amount  tubercle  bacilli  or  toxin  from  the 
focus  of  infection  as  it  does  in  febrile  cases  of  pulmonary,  renal,  or  certain 
other  forms  of  tuberculosis.  We  should  expect,  therefore,  that,  in  the 
enforced  absence  of  the  specific  poison  of  the  disease,  the  blood  would 
lack  in  specific  antibacterial  substances  on  account  of  this  lack  of  stimulus 
to  their  formation.  Corroborative  of  this  are  the  observations  of  Wright, 
Bullock,  and  many  others,  that  the  opsonic  index  is  subnormal  in  local- 
ized tuberculosis  as  in  other  local  infections  where  the  blood-supply  is 
deficient.  The  opsonic  power  in  these  cases  does  not  show  fluctuation, 
because  there  is  no  stimulus  to  produce  immunizing  response,  and  the 
blood  itself,  by  its  continuous,  although  slight,  contact  with  the  lesion, 
gradually  loses  by  combination  with  the  bacterial  substance  and  toxin 
the  opsonic  power  which  it  normally  has.  Thus  is  explained  the  absence 
of  fluctuation  and  also  the  low  opsonic  power  found  in  localized  tuber- 
culosis. 

,We  are  here  dealing  with  lowered  antibacterial  power,  because  there 
is  a  lack  of  excitation  for  the  formation  of  antibacterial  substances.  We 
step  into  the  breach,  and  furnish  this  exciting  ictus  by  means  of  inocula- 
tion with  the  specific  poison  which  the  body  needs  for  the  formation 
of  these  substances. 

The  determination  of  the  opsonic  index  before  and  after  inoculation 
has  shown  that  minute  doses  of  tuberculin  may  be  calculated  upon  to 
cause  an  immediate  rise  in  the  opsonic  power,  but  the  continuance  of 
this  elevated  opsonic  power  may  be  of  brief  duration;  that  slightly  larger 
doses  will  be  followed  on  the  day  succeeding  inoculation  by  a  diminution 
in  the  opsonic  po^^■er,  varying  in  its  degree  and  duration  upon  the  size 
of  the  dosage;  that  a  slight  fall,  lasting  a  few  hours,  though  indicating 
a  temporarily  diminished  phagocytic  resistance,  still  does  not  commonly 
produce  anything  apparent  in  the  way  of  subjective  symptoms,  locally 
or  generally;  that,  following  this  stage  of  diminished  resistance  or 
negative  phase,  there  will  succeed  a  stage  characterized  by  increased 
opsonic  power,  lasting  for  a  longer  period  than  when  a  smaller  dose  was 
used  which  did  not  produce  a  negative  phase.     If  a  still  larger  dose  be 


742  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

injected,  the  negative  phase  may  be  considerably  prolonged  and  as- 
sociated with  constitutional  disturbance,  such  as  headache,  malaise, 
and  possibly  a  febrile  reaction,  and  locally  characterized  possibly  by 
tenderness,  slight  swelling,  and  pain.  The  febrile  reaction  can  mean 
nothing  but  the  presence  in  the  blood  of  bacilli  and  toxin  which  have 
been  liberated  from  the  focus  of  disease.  This  is  uncommon  in  lymph- 
nodular  tuberculosis,  even  though  large  doses  are  used,  but  where  there 
is  a  great  involvement  of  tissue  and  less  complete  walling  off,  it  may 
be  readily  conceived  that  sufficient  bacilli  may  be  thrown  into  the  cir- 
culation to  constitute  a  menace  to  the  individual  from  the  possible 
production  of  new  foci  in  other  parts  of  the  body.  Clinically,  we  have 
instances  of  generalized  tuberculosis,  tuberculous  meningitis,  etc.,  fol- 
lowing inoculation  of  large  doses  of  tuberculin  in  some  local  infections. 
We  obviously  desire  to  avoid  the  slightest  danger  to  the  patient  as  the 
result  of  our  treatment,  and  our  aim  is,  therefore,  to  achieve  the  maxi- 
mum immunizing  response,  with  as  brief  a  period  as  possible  of  low- 
ered resistance  and  its  attendant  danger.  This  danger  is  certainly  less 
in  lymphnodular  tuberculosis  than  in  any  other  type,  excepting  perhaps 
lupus.  As  a  means  of  registering  the  response  of  the  organism  to  tuber- 
culin inoculation,  in  order  to  guide  the  dosage,  Wright  has  used  the 
opsonic  index.  It  is  not  to  be  taken  as  a  measure  of  anything  but  the 
opsonic  power.  It  may  be  considered  as  an  indicator  of  the  state  of 
excitation  of  the  antibody-forming  mechanism,  showing  whether  or  not 
it  is  or  has  been  favorably  stimulated  in  the  production  of  antibodies 
by  the  vaccine  or  autoinoculation. 

The  giving  of  tuberculin,  with  the  opsonic  idea  in  mind,  is  the  most 
conservative  method  that  can  possibly  be  de^dsed,  because  it  safeguards 
the  patient  against  the  effects  of  excessive  dosage.  The  treatment  of 
large  numbers  of  cases  with  careful  opsonic  measurements  have  fur- 
nished those  who  have  worked  under  these  most  favora.ble  conditions 
with  a  scheme  for  the  giving  of  tuberculin  which  mav  be  calculated 
to  do  no  harm,  and  to  achieve  consistent  results  without  the  labor  neces- 
sary in  the  estimation  of  large  numbers  of  opsonic  indices. 

Method  of  Treatment. — In  the  case  of  adults  the  initial  dosage  of 
tuberculin  R.  or  B.  E.  may  be  g^^  to  goi^oo  ^"^t^-  "^"^^  increase  should 
be  very  gradual,  and  may  at  the  end  of  six  months  to  a  year  reach  as  high 
as  -^Q  mg.  The  interval  between  doses  should  be  approximately  one 
week.  No  dose  should  be  increased  until  one  feels  satisfied  that  the 
patient  is  not  improving  under  it.  Ordinarily,  three  or  four  doses  of 
20^  mg.  may  be  given,  four  or  five  of  j^^  mg.,  the  same  number  of 
12^)0'  °^  10^'  °^  7^'  ^^*^  5000'  ^^^  ^*^  °^-     -^^  ^^  ^^^  ^^  ^  uncommon, 


TUBERCULOUS   SINUSES  743 

if  dosage  is  too  large,  for  the  patient  to  complain  of  swelling  and  tender- 
ness in  the  gland  being  treated.  If  this  is  not  severe,  the  same  dosage 
may  be  repeated,  and  this  commonly  without  any  exacerbation.  If 
such  occurs,  a  longer  period  may  be  allowed  to  elapse  before  the  next 
dose.  If  after  one  month's  treatment  there  is  no  evidence  of  improve- 
ment, the  dose  may  be  more  rapidly  increased.  It  should  always  fall 
short  of  producing  local  or  general  symptoms.  Some  patients  will 
require  much  larger  doses  than  others  even  at  first.  The  largest  dose 
that  I  am  giving,  among  about  fifty  glandular  cases  treated  over  a 
period  varying  from  three  months  to  eighteen  months,  is  -g^  mg, 
weekly. 

It  is  rather  common  after  the  first  few  doses  of  tuberculin  for  some 
of  the  nodes  to  break  down.  This  is,  in  a  way,  a  favorable  happening, 
because  it  renders  the  problem  for  tuberculin  of  much  less  magnitude. 
The  pus  is  never  evacuated  until  there  is  danger  of  spontaneous  rupture. 
We  delay  interference,  with  the  hope  that  as  much  of  the  node  will  break 
down  as  is  possible.  Aspiration  is  much  more  satisfactory  than  incision, 
because  there  is  less  danger  of  secondary  infection.  It  meets  e^^ery 
indication  that  surgical  measures  can  meet,  because  it  produces  free 
drainage,  admits  of  free  circulation  of  lymph  into  the  cavity,  than  which 
extensive  surgical  measures  cannot  furnish  more.  The  resulting  scar 
is  commonly  negligible. 

Sinuses. — Secondary  infection  is  common.  The  most  serious,  and 
the  least  amenable  to  treatment,  is  the  streptococcus.  Vaccine  treat- 
ment of  any  infected  sinus  is  commonly  unsatisfactory,  unless  certain 
active  measures  are  used  to  promote  antibacterial  action  locally,  because 
the  blood-supply  is  deficient,  and  even  though  the  antibacterial  power 
of  the  blood  is  high,  it  may  not  be  effective,  since  it  does  not  come  into 
contact  properly  with  the  bacteria  in  the  sinus.  We  must  promote 
discharge  in  order  to  bring  about  free  and  rapid  replacement  of  lymph. 
This  is  accomplished  by  means  of  syringing  and  local  application  of 
the  sodium  citrate  and  salt  solution.  These  secondary  infections  must 
be  treated  ordinarily  if  results  are  to  be  obtained.  I  have,  however,  neg- 
lected in  several  cases  these  secondary  infections  and  given  tuberculin 
alone  with  satisfactory  results. 

Several  cases  that  I  have  treated  have  only  healed  after  treatment  extending 
over  at  least  a  year.  One  case  is  interesting,  in  that  it  would  indicate  that  much 
larger  doses  of  streptococcus  va.ccine  may  be  necessary  in  order  to  achieve 
results,  and  possibly  that  some  modification  in  the  method  of  preparing  the 
vaccine  may  be  necessary.  This  patient  had  several  discharging  sinuses  in 
the  neck,  which  failed  to  improve  after  several  months'  treatment  with  strepto- 


744  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

COCCUS  vaccine.     She  suddenly  developed  an  acute  erysipelas,  and  coincident 
with  recovery  all  the  sinuses  healed. 

Lvmph-nodes  Developing  in  Supposedly  Arrested  Cases  of  Pulmonary 
Tuberculosis. — Examination  of  the  lungs  in  these  cases  may  show  no 
activity  in  the  focus.  Nevertheless,  the  patient  is  apt  to  give  a  history 
of  having  lost  some  weight,  and  of  not  having  felt  as  well  during  the 
period  in  which  he  has  noticed  the  development  of  a  node  in  the  axilla 
possibly,  or  in  the  neck.  There  commonly  will  be  found  to  be  no 
temperature  associated.  We  may  find  the  development  of  nodes  as- 
sociated with  extension  of  the  process  in  the  lungs.  If  this  is  the  case, 
the  nodes  should  not  be  treated,  but  the  pulmonary  condition  should 
receive  attention. 

Where  the  node  has  developed  in  an  apparently  arrested  case,  with 
no  increase  in  pulmonary  signs  and  without  temperature,  tuberculin 
must  be  given  more  guardedly  and  in  smaller  doses  at  first,  on  account 
of  the  possible  danger  of  lighting  up  the  pulmonary  lesion.  In  the 
cases  the  writer  has  treated  he  has  found  the  von  Pirquet  cutaneous 
test  gave  a  brilliant  reaction,  whereas  in  supposedly  arrested  cases, 
without  new  glandular  involvement,  we  commonly  find  a  dull  and  limited 
reaction  to  this  test.  It  is  the  writer's  custom  to  start  such  cases  with  a 
dose  of  -QQQQ  mg.  B.  E.,  and  gradually  work  up  in  the  course  of  six 
months  to  j^  mg.,  given  at  weekly  intervals.  At  first  the  patient's 
activity  should  be  extremely  moderate  and  absolutely  under  control. 
For  the  twenty-four  hours  after  inoculation  the  patient  should  rest.  If 
possible,  during  the  first  few  doses  of  tuberculin,  examination  of  the 
lungs  on  the  following  day  should  be  made.  Temperature  observations 
three  times  a  day  should  be  required,  and  as  soon  as  the  patient  is  allowed 
to  exercise  or  walk  about,  temperature  should  be  taken  before  and  after 
such  exercise.  If  this  activity  causes  a  rise  in  temperature  of  a  degree 
or  even  less,  the  patient  should  be  kept  absolutely  quiet  while  the  tuber- 
culin is  graduallv  being  increased  in  dosage,  realizing  that  febrile  reaction 
at  any  time  means  autoinoculation  induced  by  exercise  or  as  a  result  of 
the  tuberculin.  Some  of  the  most  brilliant  results  the  writer  has  ever 
seen  in  the  treatment  of  glands  by  tuberculin  have  been  accomplished 
in  this  type  of  case.  Treatment  extending  over  one  or  two  years  may  be 
necessary. 

Prognosis  in  Tuberculous  Lymph-nodes.— In  the  group  of  about 
50  cases  the  writer  has  treated  in  the  past  twenty  months  about  25  have 
been  cured.  The  minimum  of  treatment  in  cured  cases  was  three 
months,  the  maximum,  eighteen  months.     The  nodes  in  children  under 


PROGNOSIS   IN   TUBERCULOUS   LYMPH-NODES  745 

ten  yielded  more  readily  than  between  ten  and  fifteen  years,  and  those 
in  young  adults  have  yielded  better  than  in  the  older.  The  nodes  of 
short  previous  duration  yielded  better  than  those  of  long  duration. 
Nodes  that  are  caseated  do  not  yield  at  all  to  treatment,  excepting  so 
far  as  perinodular  inflammation  is  concerned.  Cure  is  taken  to  mean 
total  disappearance  of  the  node  or  diminution  in  size  to  that  of  a  pea  or 
slightly  larger.  Ten  per  cent,  of  this  group  of  cases  have  shown  very 
little  improvement  during  this  period  of  treatment.  The  rest  have  all 
shown  definite  gain  in  that  the  nodes  have  become  smaller.  In  nearly 
all  cases  there  has  been  an  improvement  in  the  general  condition,  and 
reasonable  gain  in  weight,  in  spite  of  the  fact  that  in  most  of  them 
the  conditions  of  hygiene  have  not  been  ideal,  and  have  been  improved 
very  little  over  the  conditions  before  treatment  was  begun. 

Human  tuberculin  has  been  used  in  all  cases ;  in  several  that  did  not 
improve  after  six  months'  treatment  with  tuberculin  R.  a  like  preparation 
of  the  bovine  bacillus  was  used  without  any  apparent  improvement  in 
results.  In  the  early  part  of  the  treatment  of  this  group  of  cases  tuber- 
culin R.  was  used  in  all  cases.  While  improvement  was  distinct,  it  has 
been  found  that  since  bacillus  emulsion  has  been  used  improvement  has 
been  much  more  rapid  and  definite. 

A  very  careful  and  unbiased  account  of  the  tuberculous  cases  treated  in 
Wright's  clinic,  St.  Mary's  Hospital,  London,  has  been  published  in  the 
British  Medical  Journal,  August  28,  1909,  by  Dr.  Carmalt  Jones.  There  were 
367  cases  of  all  types  treated  in  the  out-patient  department.  The  treatment 
was  carried  on  under  the  disadvantage  of  lack  of  control  over  the  conditions 
of  life  of  the  patients,  irregularity  of  their  attendance,  and  poverty.  It  was 
extremely  common  for  patients  to  cease  in  their  attendance  when  improved. 
Under  these  conditions  he  states  that  the  method  that  achieves  good  results 
deserves  full  credit.  Of  155  cases  of  adenitis  end-results  were  obtained  in 
87.  Tuberculin  B.  E.  was  used  in  minimal  doses  at  the  outset,  repeated 
every  ten  days,  and  dosage  not  increased  until  it  ceased  to  have  therapeutic 
effect.  The  minimal  dose  was  from  15000  to  5^;^o  ^S-'  the  latter  always  in 
the  case  of  children.  The  maximal  dose  for  children  under  five  was  j^^q, 
and  for  adults  rarely  exceeding  ^q.  Of  79  cases  treated  without  surgical 
measures,  27  were  cured,  22  much  better,  18  improved,  8  unchanged,  and 
4  worse.  Cure  is  defined  as  either  disappearance  of  the  gland  or  reduction  to 
the  size  of  cherry-stones.  Forty-three  in  79  cases  had  been  previously  oper- 
ated. Of  the  cured  cases,  9  out  of  27  had  been  operated;  of  the  much 
better  class,  14  of  the  22  had  been  operated;  of  the  improved,  14  out  of  18 
had  been  operated;  of  those  worse  or  unchanged,  9  out  of  12. 

Prognosis,  based  on  these  results,  will  be  that  in  8  cases  treated  5  will  show 
marked  improvement  and  2  or  3  will  be  cured,  2  irhproved  slightly,  and  i  or 


746  THERAPEUTIC   IMMUNIZATION    AND    VACCINE    THERAPY 

2  will  fail.  We  must  anticipate  the  best  results  in  young  children  and  young 
adults  from  fifteen  to  twenty-five  years  of  age.  After  this  time  results  are  not 
so  good.  The  worst  results  are  ordinarily  between  ten  and  fifteen  years  of 
age,  or  about  puberty.  Success  depends  upon  treatment  of  secondary  infec- 
tions. In  the  first  five  years  of  life  the  results  are  satisfactory,  in  the  next  less 
satisfactory,  and  so  on,  until  after  the  age  of  puberty,  when  there  is  apparently 
a  rise  in  the  resistance  or  in  the  ability  to  react  favorably  to  tuberculin.  During 
the  period  from  ten  to  fifteen  years  the  numbers  of  cases  of  improvement  are 
low,  and  there  were  more  failures  than  at  any  other  age. 

In  II  cases  the  nodes  disappeared;  these  were,  with  four  exceptions,  between 
eighteen  and  twenty-three  years.  The  most  favorable  age  for  recovery  would 
seem  to  be  about  twenty.  .  Where  the  nodes  are  of  short  duration,  recovery 
may  take  place  within  a  few  months.  In  only  3  cases  did  treatment  at  this 
age  exceed  a  year.     Relapses  after  improvement  occurred  in  11  cases. 

Hartwell  and  Streeter^  report  the  treatment  of  20  cases  of  glandular 
tuberculosis,  using  the  method  of  Trudeau,  which  seeks  to  gain  tolerance  to 
tuberculin  by  giving  fair  initial  doses  and  constantly  increasing  by  minimal 
amounts.  Initial  dosage  was  y^g  mg.  B.  E.,  increased  by  adding  the  same 
decimal  at  each  successive  inoculation  at  weekly  intervals.  The  maximal 
dose  in  this  group  was  3  mg. ;  duration  of  treatment  was  from  two  months  to 
twenty-one  months.  Five  were  nine  years  or  less  of  age,  the  rest  were  thirteen 
to  twenty-five  years.  Ten  cases  showed  as  end-results  good  palpable  glands; 
the  others  were  described  variously  as  pea-,  hazel-nut,  and  almond  sized.  The 
patients  were  seen  at  periods  from  six  months  to  one  year  treatment.  They 
state  that  tolerance  to  tuberculin  was  obtained  in  most  cases  uneventfully.  In 
a  few  instances  intolerance  was  manifested  by  constitutional  disturbance  a 
few  hours  after  inoculation,  associated  with  apathy  and  lassitude,  accompanied 
by  headache  and  backache.  No  temperature  observations  were  made.  No 
focal  reaction  was  noted  associated  with  constitutional  disturbance.  Their 
guide  as  to  intolerance  has  been  the  general  reaction.  When  this  occurs,  the 
dose  is  diminished  considerably  and  gradually  increased  again.  They  saw 
no  ill  effects  in  uncompUcated  glandular  tuberculosis.  A  tuberculous  epidid- 
ymitis was  observed,  however,  to  flare  up  under  treatment.  They  gave  as 
a  period  for  curative  treatment  of  moderately  enlarged  glands  a  year,  in  the 
massively  enlarged,  a  longer  time. 

In  this  group  of  cases  excellent  results  were  secured  by  the  use  of 
tuberculin,  without  reference  to  its  action  upon  the  opsonic  power  of 
the  blood,  although  attempt  was  made  to  avoid  systemic  reactions. 
Although  such  were  at  times  produced,  they  do  not  appear  to  have  been 
of  serious  consequence.  According  to  Jones'  statistics  of  cases  treated 
by  Wright,  using  the  opsonic  index  as  a  guide,  at  best  3  out  of  8  cases 

^  Boston  Med.  and  Surg.  Jour.,  January  6,  1910,  p.  5. 


DOSAGE   OF   TUBERCULIN  747 

were  cured.  Applying  the  same  criteria  of  cure  in  Hartwell's  smaller 
group  of  cases,  we  should  have  approximately  95  per  cent,  of  cures 
against  37^-  per  cent,  by  the  opsonic  method.  If  this  record  of  cure  can 
be  kept  up  in  a  larger  series  of  cases,  and  if  our  requirements  are  rapid 
results,  irrespective  of  occasional  unavoidable  production  of  constitu- 
tional disturbance  due  to  intolerance,  the  use  of  larger  doses  than  would 
be  allowable  under  the  opsonic  method  of  treatment  might  be  justified. 
Realizing  the  significance  of  constitutional  disturbance  in  indicating 
a  period  of  lowered  resistance  to  the  infecting  organism,  it  would  seem 
possible  that  in  a  larger  series  of  cases  some  untoward  results  might 
reasonably  develop  in  association  with  these  periods  of  lowered  re- 
sistance. If  the  results  of  a  larger  series  of  cases  indicate  that  glandular 
tuberculosis  can  be  treated  with  approximately  100  per  cent,  of  cure, 
and  with  no  untoward  results,  we  may  consider  that  we  have  in  tuber- 
culin, applied  by  the  clinical  method,  by  all  odds  the  most  remark- 
able and  efficient  medy  that  has  yet  been  offered  for  the  cure  of 
disease. 

In  comparing  the  dosage  of  tuberculin,  as  given  by  different  workers, 
we  must  consider  certain  fundamental  differences  in  the  preparation  of 
the  tuberculin.  The  dosage  of  tuberculin,  as  indicated  by  the  writer, 
is  based  upon  the  fact  that  in  the  case  of  bacillus  emulsion  the  content 
of  each  cubic  centimeter  is  stated  by  the  manufacturers  to  be  5  mg.  of, 
bacillary  substance.  A  dosage  of  jq^  '^S-j  therefore,  would  mean  that 
fraction  of  a  milligram  of  actual  bacterial  substance.  In  the  case 
of  Tuberculin  R.,  the  original  solution,  as  put  out  by  the  manufacturers, 
commonly  contains  2  mg.  of  bacillary  substance  per  cubic  centimeter, 
and  on  this  content  dosage  is  based.  Certain  workers,  however,  do  not 
base  their  dosage  on  the  content  of  the  original  tuberculin  solution  in 
bacillary  substance,  but  give  certain  fractions  of  a  milligram  of  the  orig- 
inal solution  as  a  dose.  It  is  obvious,  then,  that  a  maximum  dose  of  3 
mg.,  as  Hartv^^ell  has  used,  would  be  equivalent  to  a  dosage  of  -^  mg. 
of  solid  bacillary  substance.  This  maximum  dose  of  3  mg.,  compared 
to  the  maximum  dose  used  by  the  writer  of  -g-g-Q  mg.,  is,  therefore, 
not  so  widely  different  as  the  figures  would  make  it  appear  It  \^ould 
appear  at  first  sight  to  be  1800  times  the  writer's  maximal  dose,  but  it 
is  actually  only  10  times  that  dose. 

In  order  that  easy  comparison  of  dosage  may  be  obtainable,  it  would 
seem  advantageous  to  base  the  dosage  upon  the  actual  content  of  the 
fluid  preparations  of  tuberculin,  as  sent  out  by  the  manufacturers,  in 
bacterial  substance. 


748    ■         THERAPEUTIC    IMMUNIZATION    AND    VACCINE   THERAPY 

Hawes  and  Floyd^  report  the  treatment  of  20  nodular  cases,  of  which  18 
were  improved,  2  not  improved.  They  used  a  combination  of  bacillus  emul- 
sion and  bouillon  filtrate. 

The  method  used  was  that  of  Trudeau.^  They  state  that  larger  doses  of 
tuberculin  can  be  used  in  lymphnodular  tuberculosis  than  in  any  other  form 
of  the  disease.  They  agree  with  Jones  and  others  that  improvement  is  apt 
to  be  more  rapid  in  children,  while  in  adults  they  do  not  disappear  so  rapidly 
but  seem  to  become  encapsulated. 

Tuberculosis  of  Bone. — Unless  as  much  of  the  diseased  bone  is 
removed  as  is  possible,  the  problem  for  tuberculin  is  extremely  difi&cult. 
With  the  dead  bone  cleared  away,  this  form  of  tuberculosis  is  amenable 
to  prolonged  treatment  with  tuberculin  in  a  large  majority  of  cases. 
Here  infected  sinuses  often  complicate  and  require  appropriate  vaccines 
before  the  discharge  will  cease.  In  caries  of  the  spine,  where  the  disease 
is  extensive  and  drainage  is  imperfect,  and  there  is  temperature  associ- 
ated, the  results  cannot  be  expected  to  be  satisfactory  unless  auto- 
inoculation  is  eliminated  by  operation.  Cases  reported  from  Wright's 
clinic  by  Jones  {loc.  cit.)  consist  of  2  which  were  cured  and  3  were 
much  improved.  Western^  reports  15  cases,  7  of  which  were  cured, 
5  showed  improvement,  and  3  no  improvement.  Hawes  and  Floyd 
{loc.  cit.)  report  3  cases  of  bone  and  joint  infection,  in  which  2  were 
improved,  i  not  improved.  I  have  treated  6  cases  of  bone  disease, 
of  which  4  completely  healed  after  from  nine  to  eighteen  months' 
treatment.  One  case,  tuberculous  ribs,  still  has  very  slight  discharge 
from  one  sinus,  previously  having  had  profuse  discharge  from  eight  or 
ten.  In  all  these  cases  there  has  been  a  definite  improvement  in  general 
condition  and  most  have  gained  weight.  The  maximum  dosage  of 
tuberculin  B.  E.  used  was  ^q^q  0  ^§-  °^  solid  substance.  The  sixth  case 
was  one  of  tuberculosis  of  the  lumbar  vertebras,  in  which  it  is  impossible 
to  maintain  good  drainage.  The  temperature  continued  elevated,  and 
after  six  months'  treatment  there  was  apparently  no  change  in  the  con- 
dition for  the  better. 

The  dosage  of  tuberculin  in  bone  and  joint  cases  is  generally  about 
the  same  as  that  used  where  lymph-nodes  are  treated.  In  the  case  of 
joints  of  short  duration  the  initial  dosage  should  be  a  little  smaller. 
Supplementary  treatment,  such  as  fixation,  is  usually  imperative.  The 
duration  of  treatment  depends  upon  the  previous  chronicity  and  extent 
of  the  involvement  and  the  age  of  the  patient.     In  the  case  of  bone  in- 

^  Boston  Med.  and  Surg.  Jour.,  January  6,  1910,  p.  5. 
^  Amer.  Jour.  Med.  Sci.,  June,  1907,  p.  18. 
^  Lancet,  November  23,  1907,  p.  1450. 


TUBERCULOUS    JOINTS:    LUPUS  749 

volvement,  removal  of  carious  bone  renders  the  problem  for  tuberculin 
much  more  simple. 

Tuberculous  Joints. — The  problem  for  tuberculin  in  these  cases 
depends  largely  upon  the  character  of  the  tissues  involved.  If  it  be 
merely  the  soft  tissues,  without  extensive  necrosis  and  without  much 
bone  involvement,  the  expectation  of  improvement  will  be  much  greater 
than  in  cases  of  long  duration  with  bone  involvement.  Improvement 
or  lack  of  improvement  in  these  conditions  depends  largely  upon  the 
state  of  the  blood-supply  to  the  infected  part.  If  the  blood-supply  is 
cut  off  by  fibrous  or  caseated  tissue  or  pus  from  coming  into  contact 
with  the  bacteria  in  the  focus,  it  is  obvious  that,  even  though  the 
blood-stream  be  fortified  in  its  content  of  antibodies,  results  will  not 
be  forthcoming.  Tuberculin  should  only  be  used  in  conjunction  with 
other  measures  which  have  proved  themselves  clinically  valuable  in 
the  conduct  of  these  cases.  Western  reports  14  cases  cured,  5  cases 
impro^•ed,  5  cases  with  no  improvement,  and  2  cases  with  slight  im- 
provement, in  26  cases  treated.  Of  the  5  cases  showing  no  improve- 
ment, 2  were  over  sixty  years  of  age. 

Raw  ^  reports  27  cases  which  were  chronic  or  subacute,  and  ob- 
tained the  best  results  where  there  were  suppuration  and  sinuses.  My 
own  experience  has  been  limited  to  the  treatment  of  4  cases,  in  i  of 
which  there  w^as  decided  improvement  after  six  months'  treatment,  in 
a  second  there  was  complete  cure  and  function  was  apparently  obtained, 
and  the  other  2  were  lost  sight  of. 

There  is  not  the  slightest  question  but  that  tuberculin  has  distinct 
value  in  many  cases  of  joint  infection.  Its  curative  value  is  limited  by 
the  condition  of  the  focus  as  to  whether  or  not  the  blood-supply  can  be 
made  sufficient.  Methods  for  diagnosis  and  for  decision  of  cure  by 
means  of  the  opsonic  index  have  been  discussed. 

Lupus 
Success  in  the  treatment  of  any  localized  infection  depends  on  either 
the  condition  of  the  normal  blood-supply  or  the  facility  with  which  it 
is  possible  to  induce  an  increased  circulation  in  the  affected  part,  and 
thus  bring  into  application,  where  needed,  the  effective  antibacterial 
power  of  the  blood-stream.  In  lupus  of  the  dry  type  the  blood-supply  is 
not  only  naturally  more  or  less  cut  off,  but  also  it  is  difficult  to  induce 
sufficient  increase  in  the  local  supply  to  render  tuberculin  particularly 
effective  as  an  agent  for  cure.  On  the  other  hand,  lupus  of  the  ulcera- 
ti^•e  type  offers  a  better  field  for  tuberculin  therapy,  because  it  is  possible, 

^  Lancet,  February  15,  1908,  p.  480. 


750  THERAPEUTIC   IMMUNIZATION    AND    VACCINE    THERAPY 

by  means  of  furthering  discharge  from  the  ulcerating  surfaces,  to  induce 
a  more  free  circulation  of  blood  and  lymph  in  the  focus  of  infection.  The 
results  of  tuberculin  treatment  in  this  type  of  lupus  are,  in  general,  re- 
ported to  be  much  more  satisfactory  than  in  the  dry  type,  in  which  there 
is  no  vent  for  discharge,  and  in  which,  therefore,  circulation  of  lymph 
in  the  part  cannot  be  effected  so  satisfactorily.  If  tuberculin  is  to  be 
efficient  in  either  type  of  case,  appropriate  measures  must  be  used  to 
cause  determination  of  lymph  into  the  lesion  by  means  of  heat,  cupping, 
the  use  of  :v-ray  or  Finsen  ray.  It  is  possible  that  the  two  latter  may 
have  not  only  an  effect  in  the  production  of  increased  blood-supply,  but 
also  some  degree  of  bactericidal  action. 

Western^  records  the  opsonic  power  of  the  blood  in  80  cases  of  lupus. 
Twenty-two  of  these  were  below  0.75,  that  is,  the  opsonic  power  was  f  of  the 
normal.  The  rest  varied  from  this  point  to  i  J  times  the  opsonic  power  of  the 
normal. 

Bulloch^  shows  in  a  series  of  150  cases  that  the  opsonic  indices  ranged  from 
0.25  to  1.4,  and  that  about  77  per  cent,  of  these  cases  ranged  from  -^  to  -^  of 
the  normal.  Patients  upon  whom  these  blood  examinations  were  made  were 
treated  by  .v-ray  or  the  Finsen  light  in  Dr.  Sequeira's  cUnic  at  the  London 
Hospital.  The  observations  which  were  made  by  Bulloch  and  Sequeira, 
showed  that,  where  the  opsonic  index  was  helow  normal,  the  v-ray  or  Finsen 
ray  had  little  power  to  stamp  out  the  disease,  whereas  when  the  indices  were 
above  normal,  they  were  impressed  that  the  cases  did  well.  They  attribute 
the  improvement  in  the  latter  group  of  cases  not  to  any  bactericidal  effect  of 
the  light  treatment,  but  state  that  it  is  not  improbable  that,  in  addition  to  the 
tissue  reaction  produced,  the  role  of  the  Finsen  hght  is  to  produce  determina- 
tion of  blood  to  the  part.  If  the  plasma  is  deficient  in  opsonin,  as  it  is  in  one 
of  these  groups  (having  low  opsonic  indices),  the  result  of  this  determination 
of  blood  would  be  less  effective  than  where  a  large  quantity  of  opsonin  was 
present,  and  this  is  consistent  with  the  results  of  treatment.  This  suggested 
that  injections  of  tuberculin  to  raise  the  opsonic  power,  associated  with  Hght 
treatment  to  cause  determination  of  blood  to  the  part,  would  be  the  proper 
plan  to  pursue. 

Western^  states  that,  in  looking  through  the  cHnical  history  of  80  cases 
of  lupus  which  have  been  under  treatment  other  than  tuberculin,  his  impres- 
sion corresponds  with  that  of  Dr.  Bulloch  as  quoted.  He  states  there  are 
certain  exceptions,  however,  in  which  patients  with  low  indices  have  shown 
definite  rise  in  the  opsonic  power  of  the  blood  following  such  application  of 
light  treatment.     He  explains  this  by  the  supposition  that  the  reaction  caused 

^  Lancet,  November  16,  1907. 

^  Trans.  Path.  Soc,  London,  1905,  vol.  Ivi,  pt.  3. 

^  Lancet,  November  16,  1907,  p.  1378. 


PROGNOSIS  WITH  TUBERCULIN  TREATMENT  751 

by  the  application  of  Finsen  light  or  the  :r-ray  is  to  produce  local  dilatation  of 
the  blood-vessels,  flushing  the  seat  of  infection,  at  the  same  time  producing 
autoinoculation,  which  results  in  an  immunizing  response  as  registered  by  the 
increase  in  the  opsonic  power. 

Western  states  that  in  his  experience  lupus  with  ulceration  responds  to 
tuberculin  better  than  the  dry  type.  He  attributes  this  to  the  possibility  of 
producing  better  circulation  in  the  former  than  in  the  latter.  He  advises 
cupping  and  fomentations  as  measures  to  bring  this  about.  Reports  7  cases, 
with  improvement  or  cure  in  all  but  i .  Finsen -ray  alone  has  been  used  fairly 
successfully  in  the  treatment  of  lupus,  but  the  tendency  to  relapse  is  greater 
when  the  Finsen  ray  is  used  solely  than  when  tuberculin  is  used  in  addition. 

Carmalt  Jones,  reporting  the  cases  treated  in  Wright's  clinic,  London, 
gives  the  following  statistics: 

Lupus,  2;}  cases,  ages  fifteen  to  twent}'-five.  Under  fifteen  cases  were  rare. 
Three  cases  cured,  8  much  better,  9  better,  i  unchanged,  and  2  unknown. 
Dosage  was  large,  beginning  in  3  with  Jwiob'  ^^^  reaching  a  maximum  of 
2000  to  5000-  Secondary  infection  in  one-half  the  cases.  Duration  of  treat- 
ment, two  years  in  successful  cases.     Relapses,  five  times. 

Prognosis  with  Tuberculin  Treatment. — According  to  these 
statistics,  it  would  appear  that  i  case  in  8  may  be  cured,  and  i  in  2 
much  improved  after  prolonged  treatment. 

This  does  not  look  encouraging;  nevertheless,  tuberculin  would 
appear  to  be  indicated  in  case  the  opsonic  power  of  the  blood  is  sub- 
normal. In  all  cases,  if  surgery  is  contraindicated,  treatment  by  x- 
ray,  or  Finsen-ray  in  addition,  seems  to  give  the  best  results,  for  the 
reason  that,  beyond  the  possible  stimulating  effect  they  may  have  upon 
the  tissue-cells,  or  the  bactericidal  effect  upon  the  organisms  present, 
which  they  may  have,  they  appear  to  have  an  important  action  in  causing 
a  determination  of  blood  to  the  affected  part.  Lupus  is  rare  in  some 
out-patient  clinics.  The  writer  has  treated  3  cases,  during  periods 
ranging  from  three  to  six  months,  with  a  total  lack  of  improvement. 
X-ray  and  Finsen  light  were  not  used  as  adjunct  measures.  If  pos- 
sible, excision  is  the  quickest  and  best  treatment.  The  situation, 
extent,  and  considerations  as  to  scar  formation  furnish  indications  as  to 
the  advisability  of  surgical  measures. 

GENITO-URINARY  TUBERCULOSIS 

Renal  Tuberculosis. — It  is  decidedly  unwise  for  any  one,  no 
matter  how  expert  in  the  giving  of  tuberculin,  to  institute  treatment  in 


752  THERAPEUTIC    IMMUNIZATION   AND    VACCINE    THERAPY 

any  case  of  genito-urinary  tuberculosis  until  the  question  of  extent  of 
involvement  of  the  kidneys  and  other  structures,  and  the  question  of 
extirpation,  has  been  thoroughly  investigated  and  considered  by  the 
surgeon  trained  in  the  special  methods  of  genito-urinary  diagnosis  and 
treatment. 

Expectation  that  the  exhibition  of  tuberculin  in  extensive  renal 
involvement,  associated  with  disintegration  and  extensive  caseation  of 
the  kidney,  will  take  the  place  of  extirpation  of  the  organ  is  entirely 
unfounded.  It  may  reasonably  be  expected  that  the  proper  use  of  tuber- 
culin may  maintain  the  blood-stream  in  a  condition  of  increased  resist- 
ance to  the  tubercle  bacillus,  but,  both  in  theory  and  in  practice,  it  is 
unjustifiable  to  risk  the  patient's  life  by  leaving  unmolested  a  disinte- 
grated useless  kidney,  on  the  expectation  that  the  blood-stream  will,  by 
means  of  its  high  antituberculous  power,  be  able  to  produce  resolution. 
It  is  obviously  impossible  to  transfer  the  antibacterial  elements  of  the 
blood-stream  into  a  mass  of  caseated  material,  or  even  to  conceive  of  a 
sufficiently  active  circulation  in  the  infected  tissue  surrounding  such  a 
mass  of  caseous  material  to  cause  the  destruction  of  the  tubercle  bacilli 
present. 

Involvement  of  both  kidneys,  if  extensive,  may  contraindicate  ex- 
tirpation of  either.  The  use  of  tuberculin  in  such  cases  has  been  found 
to  produce  distinct  amelioration  in  the  pain,  frequency  of  micturition 
and  temperature,  and  may  be  considered  a  decidedly  useful  measure  for 
the  temporary  relief,  although  from  the  start  such  cases  are  beyond  hope 
of  cure. 

A  case  of  this  type  is  reported  by  Walker,^  and  briefly  is  as  follows : 
After  three  weeks'  treatment  with  tuberculin,  pain  and  hematuria  dis- 
appeared, and  frequency  of  micturition  diminished.  Temperature  fell 
to  99°  F. ;  weight  increased.  After  six  weeks,  no  bacilli  were  found  in 
the  urine.     After  three  months,  the  patient  died  of  renal  failure. 

He  states  that  renal  tuberculosis  with  occlusion  of  the  ureter,  pro- 
ducing, a  resulting  accumulation  of  caseous  material,  offers  no  expecta- 
tion of  cure  under  tuberculin.  The  frequent  involvement  of  the  ureter 
in  the  tuberculous  process  renders  possible  in  such  cases  occlusion  and 
accumulation  of  pus  under  pressure.  Walker  {loc.  cit.)  refers  to  Fen- 
wick's  statement  that  actual  harm  inay  result  from  administration  of 
tuberculin  when  the  ureter  is  involved,  on  account  of  the  swelling  in  the 
mucous  membrane  which  may  follow  its  use  with  possible  occlusion 
resulting. 

Such  increase  in  swelling  might  result  from  a  ''focal"  reaction  in  an 

^  Practitioner,  London,  May,  190S,  p.  723. 


GENITO-URINARY    TUBERCULOSIS  753 

already  infected  and  swollen  mucous  membrane  of  the  ureter,  induced  by 
a  large  dose  of  tuberculin.  These  considerations  furnish  earnest  reason 
for  the  use  of  small  dosage  of  tuberculin,  and  of  an  increase  in  dosage 
so  gradual  that  nothing  in  the  way  of  reaction,  local  or  general,  is  pro- 
duced in  the  treatment  of  any  case  of  renal  tuberculosis. 

Tuberculin  should  be  of  the  most  advantage  in  the  early  stages  of 
renal  tuberculosis.  It  is  uncommon,  however,  to  arrive  at  a  diagnosis  at 
this  early  period,  because  the  first  evidence  noted  by  the  patient,  such  as 
cystitis,  may  not  appear  until  long  after  the  disease  has  gained  consider- 
able headway  in  the  kidney. 

Given  a  diagnosis  of  tuberculous  kidney  in  its  early  stage,  the  ques- 
tion of  tuberculin  as  against  extirpation  cannot  be  settled  until  more 
cases  are  reported  with  ultimate  results,  and  compared  to  those  obtained 
by  extirpation.  A  trial  of  tuberculin  cannot  be  dangerous  if  it  be  ad- 
ministered carefully. 

Walker  reports  the  treatment  of  an  apparently  early  case  as  follows : 

A  history  of  sudden  attack  of  pain  in  kidney,  shooting  into  groin  and  testicle,  followed 
by  dull  renal  ache.  Passed  blood.  No  bladder  symptoms.  Pott's  disease  twelve  years 
before  with  cold  abscess.  At  about  the  same  time  amputation  of  left  foot  for  tuberculous 
disease.  Kidneys  not  tender;  right  slightly  enlarged.  Tuberculin  j-|  mg.  once  a  month, 
gradually  increased  to  J  mg.  "Almost  from  the  first  weight  increased.  Blood  has  not 
appeared  in  the  urine  since  treatment  commenced."  For  eight  months  the  pain  in  the 
kidney  continued  troublesome.  After  that,  it  suddenly  diminished,  until  January,  1906 
(seventeen  months'  treatment),  when  it  disappeared.  Reduction  in  the  dosage  of  j-jVa  rng, 
was  followed  by  a  noticably  increased  pain.  In  July,  1906,  dose  was  raised,  and  in  Feb- 
ruary, 1907,  patient  stated  he  had  had  no  pain  since  the  increased  dose.  There  was  less 
pain  with  larger  doses. 

Carmalt  Jones  reports  the  cases  of  renal  tuberculosis  treated  in 
Wright's  clinic.  Of  the  cases  treated,  2  were  considered  cured,  2 
"better,"  2  "somewhat  better,"  and  i  dead. 

The  writer  has  used  tuberculin  in  i  case  of  renal  disease  in  which 
the  organ  was  considered  to  be  not  sufficiently  disintegrated  to  demand 
extirpation. 

The  patient,  a  man  of  about  fifty,  had  suffered  from  cystitis  for  over  a  year.  His 
ureters  had  been  catheterized.  The  urine  from  the  right  kidney  was  cloudy,  due  to  colon 
bacilli  and  pus.  That  from  the  left  kidney  was  more  clear.  The  writer  was  advised  that  no 
tubercle  bacilli  had  been  found  in  the  sediment,  and  he  was  asked  to  treat  the  case  as  one 
of  colon  pyelitis  and  cystitis.  In  order  to  rule  out  tuberculosis  he  inoculated  a  guinea-pig, 
which  died  six  weeks  later,  from  generalized  tuberculosis.  ■  During  this  period  colon 
vaccine  was  given,  with  some  temporary  improvement,  manifested  by  lessened  frequency 
in  micturition,  almost  total  disappearance  of  colon  bacilli,  and  diminution  in  the  amount 
of  pus.     The  von  Pirquet  skin  reaction  was  intense. 

Tuberculin  was  given  at  weekly  intervals  as  soon  as  a  diagnosis  had  been  made  for 
a  period  of  four  months.  Dosage  from  2n4foo  ™S-  ^^  bacillus  emulsion  to  — ^  mg.  Al 
48 


754  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

the  end  of  the  fourth  month's  treatment  the  patient  complained  of  dull  pain  and  a  sensa- 
tion of  fulness  in  the  right  side  of  the  abdomen,  high  up.  There  was  suggestion  of  a  mass 
to  the  right  of  the  umbiHcus,  deeply  situated.  He  was  referred  back  to  the  surgeon, 
operated,  a  large  collection  of  pus,  invohing  pehis  of  the  kidney  and  ureter,  was  found. 
He  soon  after  died  of  pneumonia.  Dosage  of  colon  vaccine  was  from  10,000,000  to 
100,000,000  everv  four  or  live  days. 


This  case  is  of  interest  for  several  reasons:  First,  in  diagnosis,  the 
presence  of  colon  bacilli  in  large  numbers  in  catheter  specimens  of 
urine  from  the  ureter  should  suggest  the  possibility  of  tuberculosis  as  a 
fundamental  cause,  inasmuch  as  the  t\\'0  organisms  are  so  commonly 
associated  in  these  infections;  second,  the  absence  of  tubercle  bacilli 
in  the  smears  should  lead  one  to  inoculate  a  guinea-pig  with  the  sediment 
in  order  to  secure  final  evidence  for  or  against  tuberculosis;  third,  it 
suggests  the  difficulty  of  determining  the  extent  of  the  tuberculous  process 
in  the  kidney;  fourth,  it  illustrates  the  possibility  of  occlusion  of  the  ureter 
in  any  case  where  the  same  is  invoh'ed  in  the  diseased  process. 

We  may  have,  therefore,  at  the  outset,  through  disintegration,  with- 
out any  definite  evidence  one  way  or  another,  or  we  may  have  developed 
later,  through  occlusion  of  the  ureter,  an  impossible  problem  for  tuber- 
culin, which  could  in  no  way  be  foreseen. 

Vesical  Tuberculosis  Associated  with  Renal  Involve- 
ment.— Renal  tuberculosis  is  commonly  complicated  by  secondary 
bladder  infection  by  the  same  organism.  It  may  be  difficult  to  say  which 
is  the  original  seat  of  infection,  bladder  or  kidney.  Cystitis,  associated 
with  renal  disease,  may  clear  up  after  extirpation  of  the  diseased  organ. 
Walker  {loc.  cit.)  states  that  in  some  cases  the  cystitis  appears  to  be  due, 
not  to  actual  tuberculous  infection  of  the  bladder,  but  to  the  irritation 
caused  by  the  deposit  from  the  kidney.  In  claiming  cure  of  tuberculous 
cystitis  by  removal  of  the  kidney,  this  possibility  must  be  borne  in  mind. 

When,  in  spite  of  extirpation,  the  cystitis  persists,  the  use  of  tuber- 
culin is  indicated.  Walker  concludes  that  it  is  a  valuable  adjunct  to 
operation.     He  reports  the  following  case  {loc.  cit.) : 

Patient  had  constantly  aching  left  kidnej'  eight  months.  Worse  in  morning,  aggra- 
vated by  exercise.  Nocturnal  micturition  for  six  months.  Blood  in  urine.  Frequency, 
half  hourly  in  day,  two  hourly  at  night.  Left  kidney  large  and  tender.  Cystoscope  showed 
general  tuberculous  cystitis,  left  ureter  retracted.  One  month  later  large  tuberculous 
left  kidney  removed  and  a  month  later  tuberculin  begun.  During  twelve  months'  treat- 
ment there  was  increase  in  weight,  frequency  of  micturition  became  hourly  instead  of 
half  hourly,  pain  less;  improvement  was  slow  but  undoubted. 

A  brief  summary  of  a  case  of  this  type  treated  by  the  writer  is  as  fol- 
lows: 


VESICAL    AND    RENAL    TUBEECULOSIS  755 

Increased  frequency  for  over  five  years.  Three  months  before  operation  cystitis 
became  severe;  incontinence  of  urine.     Much  pus  and  many  tubercle  bacilli  found. 

At  operation  right  kidney  and  ureter  were  found  to  be  extensively  tuberculous  and  were 
removed. 

When  seen  by  the  writer,  two  months  ofter  operation,  there  was  a  free  discharge  from 
two  operative  wounds.  Urine  foul,  cloudy,  contained  pus  and  tubercle  bacilli,  and  large 
numbers  of  colon  bacilU.  Micturition  during  the  day  even,-  twenty  minutes,  at  night  ten 
or  fifteen  times.  Excessive  vesical  pain.  Temperature  ioo°  to  102°  F.  Prostration, 
emaciation.     Bad  prognosis  given  by  the  attending  surgeon. 

Tuberculin  R  was  given  at  weekly  intervals,  beginning  with  -^  -^ —  mg.  (bacillary 
substance).  Temperature  normal  after  two  weeks.  Dosage  of  scVff  mg.  at  end  of  two 
months.  General  condition,  strength,  weight,  appetite,  showed  at  this  time  a  decided  gain. 
Pain  and  frequency  did  not  improve  commensurately.  A  colon  bacillus,  isolated  from 
urine,  was  agglutinated  by  the  patient's  serum  at  a  dilution  of  i:  128.  Colon  vaccine 
prepared  and  injected  twice  a  week  at  first.     Initial  dose,  10,000,000. 

Before  the  end  of  two  weeks  there  was  less  pain  and  frequency,  the  urine  appeared  a 
httle  less  cloudy  and  less  foul.  In  the  second  month  of  treatment,  with  the  combined  vac- 
cine, the  urine  became  comparatively  clear.  After  six  months  from  the  start,  the  wounds 
had  healed,  the  urine,  no  longer  foul,  contained  very  little  sediment.  Urination  every 
two  hours  in  day,  less  often  at  night,  associated  with  ver}^  slight  burning.  At  this  time 
patient  had  been  up  and  about  increasingly  for  two  months;  had  gained  considerable 
weight. 

At  the  time  of  writing  (March,  19 10),  the  patient  had  received  tuberculin  weekly 
twenty-one  months  with  occasional  breaks.  The  maximum  dosage,  ^^jj  mg.  For  six 
months  colon  vaccine  was  given,  at  first  twice  weekly  and  later  once  a  week.  Maximum 
dosage,  60,000,000.  It  was  omitted  about  a  year  ago.  The  urine  sediment  was  slight,  and 
few  colon  bacilli  were  to  be  found  on  recent  examination.  It  still  contains  tubercle  bacilli, 
as  recent  inoculation  experiment  proved.  Micturition  everj^  three  to  five  hours,  occasion^ 
ally  once  or  twice  at  night.  No  fjain.  Gain  in  weight  approximated  at  30  pounds.  Is 
able  to  attend  to  household  duties  and  to  go  about  without  discomfort.  She  states  that 
she  feels  better  than  she  has  for  several  years. 

There  are  certain  features  of  this  case  that  are  worthy  of  note: 
First,  the  immediate  improvement  in  the  cystitis  following  the  ad- 
ministration of  colon  vaccine,  there  having  been  no  improvement  in 
this  regard  during  the  two  months  of  exclusive  tuberculin  treatment; 
second,  the  fact  that  the  colon  bacilli  were  but  few  in  the 
urine  after  six  months  of  treatment  with  colon  vaccine;  third,  that, 
although  the  maximum  dosage  of  colon  vaccine  was  but  60.000,000,  and 
the  last  dose  was  given  approximately  a  year  ago,  the  immunity  estab- 
lished has  apparently  continued  to  the  present  time;  fourth,  the  presence 
of  li^•ing  tubercle  bacilli  in  the  urine  indicates  that  the  process  is  still 
active  somewhere,  but  the  patient's  excellent  condition,  the  absence  of 
temperature,  indicates  that  she  has  at  present  a  well-defined  degree  of 
immunity;  fifth,  the  presence  of  these  bacilli  indicates  that  e\"ery  possible 
measure  should  be  made  use  of  to  increase  the  patient's  resistance,  and, 
particularly,  that  we  must  maintain  the  antituberculous  power  of  the 
blood-stream  at  as  high  a  degree  as  possible  by  the  use  of  tuberculin; 


756  THERAPEUTIC    IMMUNIZATION    AND    VACCINE    THERAPY 

sixth,  it  is  interesting  to  note  that  the  patient  is  able  to  say,  based  on  her 
subjective  symptoms  of  well-being,  or  the  opposite,  following  a  dosage  of 
vaccine,  as  to  whether  the  dose  as  given  is  increased  or  dimLnished.  It 
has  been  found  in  every  instance  in  which  the  dosage  has  reached  2  q'^q  q 
mg.  the  patient  does  not  feel  as  well  for  three  or  four  days  after  in- 
oculation. It  has  been  found  that  a  dosage  of  from  g  q^q  q  to  ^q-q  q  mg. 
(bacillary  substance)  is  the  most  satisfactory  dosage  with  which  to  main- 
tain the  present  excellent  condition.  It  is  planned  gradually  to  increase 
the  dose  by  minute  increments,  that  is,  from  g  q-q  q  to  7-5-Vo''  ^^^  ^^^^  ^° 
j-Q^-Q  mg.  and  so  on,  with  the  expectation  that  in  the  next  six  months  a 
dosage  of  ywo"  ™&-  '^'eekly  may  be  well  borne.  There  has  been  in  the 
treatment  of  this  case  at  no  time  any  suspicion  of  severe  subjective 
symptoms  following  either  the  colon  vaccine  or  the  tuberculin. 

Vesical  Tuberculosis  Without  Apparent  Renal  Involve- 
ment.— There  may  occur,  according  to  Walker  (loc.  cit.),  a  considerable 
number  of  cases  of  tuberculous  cystitis,  unaccompanied  by  demonstrable 
renal  involvement.  Of  42  cases,  he  found  10  in  which  the  disease  was 
apparently  confined  to  the  bladder,  and  32  in  which  foci  were  found  in 
other  parts  of  the  urogenital  system.  In  23  of  these  32  the  other  involve- 
ment was  in  the  genital  system. 

When,  as  a  result  of  the  application  of  the  usual  methods  of  diag- 
nosis, it  is  concluded  that  the  bladder  is  the  chief  seat  of  involvement, 
we  have  a  condition  unsuitable  for  surgical  treatment  and  unsatisfactory 
with  other  usual  methods. 

We  have  to  deal  with  a  tubercular  infection  of  a  mucous  membrane, 
ulcerated  and  indurated.  Such  lesions  are  definitely  known  to  be  amen- 
able to  tuberculin. 

Again  quoting  Walker  {loc.  cit.) : 

"In  such  cases  the  best  results  may  be  obtained  from  tuberculin  treatment."  He 
states  that  sometimes,  after  two  or  three  injections,  the  patient  •wall  report  improvement. 
Less  often  the  symptoms  persist  in  increased  or  lessened  severity,  and  improvement  is  only 
obtained  after  many  months  of  treatment.  The  patient  first  experiences  increased  vigor, 
pain  diminishes  and  disappears,  and  calls  to  micturition  become  less  troublesome.  From 
a  frequency  of  fifteen  minutes  during  the  day  and  incontinence  at  night,  improvement 
to  two  hours  through  the  day  and  once  or  twice  at  night  may  be  obtained  in  several  months. 
Hematuria  gradually  ceases.  The  urine  remains  for  a  long  time  without  change,  but  may 
eventually  become  clear,  and  the  urinary  pigment,  which  was  deficient,  increased.  The 
patient  puts  on  weight. 

He  selects  the  following  case  from  a  few  in  which  the  tuberculous 
process  has  apparently  been  arrested: 

Man,  thirty-one,  in  July,  1903,  had  hematuria  and  hemoptysis.  For  four  years 
cystitis  symptoms  had  increased  gradually.      Cystoscope  sho\\ed  ulceration  left  side  of 


VESICAL    TUBERCULOSIS 


757 


bladder.  Groups  of  fine  tubercles  found. .  Four  months  treated  with  drugs.  Symptoms 
the  same.  Steadily  lost  weight.  Tuberculin  begun  November,  1903,  ^^  mg.,  repeated 
every  two  weeks.  January,  1904,  urine  unchanged.  He  ceased  to  lose  flesh,  held  his 
urine  four  hours  during  the  day,  rose  once  at  night.  Much  stronger,  and  had  regained  former 
figure.  Cystoscope  showed  groups  of  tubercles,  but  less  ulceration.  Hemoptysis  in  March, 
1904,  and  about  weekly  during  the  early  part  of  the  year.  He  began  to  gain  flesh,  and 
appearance  showed  improvement.   In  1904  burst  of  hemoptysis  and  hematuria.  September, 

1904,  to  Januar}',  1905,  had  gained  one  stone  and  a  half  in  weight.     Cystoscope,  June, 

1905,  showed  few  fine  tubercles;  ulceration  had  healed.  September,  1905,  no  pain  or 
hematuria.  Urinated  three  or  four  times  a  day,  not  at  all  at  night.  Urine  still  hazy, 
trace  of  pus.  Januar}',  1906,  injection  reduced  to  ttj'ittt  mg.  for  three  weeks.  Blood  ap- 
peared in  urine  and  was  present  some  weeks.  It  disappeared  and  the  urine  gradually 
cleared,  -u-ith  increased  doses  of  tuberculin.  Urine  became  absolutely  clear,  remained  so 
several  months.  July,  1907,  attack  of  cystitis.  Urine  cloudy,  no  T.  B.  found,  numerous 
staphylococci.     Recovered  from  this  attack  of  staphylococcus  cystitis  and  feels  well. 

Jones  reports  the  cases  of  tuberculous  cystitis  treated  in  Wright's 
cKnic  as  follows: 

Two  cases  cured,  4  much  better,  8  better,  meaning  either  some  relief  from  pain  or 
frequency  of  micturition.  One  case  was  no  better,  i  worse,  and  i  unknown.  There 
were  relapses  in  5  cases.  In  13  cases  there  was  secondary  colon  infection.  In  10  of  the 
successful  cases  initial  dose  was  less  than  ,  ^  \^.  but  often  --J-—-  mg.      After  a  time  it 

15,000  2o,000 

was  raised  gradually  to  ^^ff.  Serious  results  may  follow  large  initial  doses.  Treatment  of 
successfvd  cases  averaged  one  year  two  months.     Five  or  6  were  treated  six  months  or  less. 

The  writer  has  treated  a  case  of  genito-urinary  tuberculosis,  which 
in  its  early  history  furnishes  an  excellent  illustration  of  the  course  of  an 
untreated  case  of  tuberculous  bladder,  apparently  unassociated  with 
renal  disease: 

In  early  October,  1908,  "F.  G.,"  male,  about  twenty-eight  years  old,  was  referred  for 
treatment.  For  ten  years  he  had  suffered  from  frequent  micturition,  generally  every  two 
or  three  hours.  For  three  or  four  years  had  passed  a  little  blood  once  or  twice  each  year. 
At  times  there  was  considerable  pain  and  burning  on  micturition,  but  this  was  not  constant. 
Four  years  before  the  above  date  the  symptoms  of  cystitis  became  marked,  and  when  blood 
appeared,  he  was  referred  to  a  surgeon  for  observation.  Cystoscopy  was  at  the  time  per- 
formed by  J.  H.  Cunningham,  Jr.,  who  found  several  ulcerated  areas  in  the  mucous  mem- 
brane and  made  a  positive  diagnosis  of  tuberculosis.  During  the  following  four  years  he 
occasionally  passed  blood,  had  some  pain  on  micturition.  Frequency,  every  two  or  three 
hours,  once  or  twice  at  night.  Urine  generally  not  cloudy.  His  general  health  continued 
to  be  fairly  good  although  untreated.  In  October,  1908,  he  developed  a  swollen  testicle, 
which  was,  when  the  writer  saw  it,  the  size  of  a  clenched  fist.  It  had  become  swollen 
in  a  few  days;  was  only  slightly  tender.  His  physician  beHevcd  it  to  be  due  to  the  gono- 
coccus,  but  there  was  no  histor}'  of  exposure  or  clinical  evidence  of  the  disease.  The 
von  Pirquet  cutaneous  reaction  was  intensely  positive.  In  a  short  time  the  tissues  broke 
down,  fluctuation  was  made  out,  and  considerable  thick  pus  was  aspirated.  No  pyogenic 
organisms  were  present.  A  guinea-pig  inoculated,  killed  after  four  weeks,  showed  tubercle 
bacilli  in  the  mesenteric  glands,  inguinal  glands,  and  tubercles  were  found  studding  the 
peritoneum. 


758  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

The  sequence  of  events  in  this  case  and  the  observations  furnish 
clean-cut  evidence  of  a  tuberculous  cystitis  extending  over  a  period  of 
years  and  final  extension  to  the  testicle. 

It  indicates  that  in  an  apparently  healthy  individual  tuberculosis 
may  exist  in  the  bladder  for  a  long  time,  and  illustrates  the  tendency  of 
bladder  tuberculosis  to  extend  to  other  organs  of  the  genital  system. 
It  is  particularly  interesting,  because  of  the  sequence  of  events  in  the 
same  case  following  the  use  of  tuberculin  as  treatment  over  a  consider- 
able period.  The  treatment  of  this  case  will  be  considered  under  the 
next  heading. 

Vesical  Tuberculosis  Associated  with  Tuberculosis  of 
the  Genital  System. — In  23  cases  cited  by  Walker  (loc.  cit.)  tuber- 
culosis was  found  to  be  coexistent  in  the  bladder  and  in  some  of  the 
genital  organs.     This  association  is  very  commonly  met  with. 

He  states  that  his  patients  steadily  lost  ground  under  various  local 
and  general  treatment,  and  that  he  considered  them  eminently  suited 
for  tuberculin  treatment;  that  in  none  of  them  was  he  able  to  bring  about 
a  cure,  though  he  treated  them  over  long  periods.  In  most  cases  a  con- 
siderable amelioration  of  symptoms  was  obtained.  The  distressing 
frequent  and  urgent  micturition  is  sometimes  diminished  to  a  remarkable 
degree. 

One  illustrative  case,  a  man  of  thirty-eight,  when  seen  had  symptoms  of  cystitis  for 
eighteen  months.  Left  seminal  vesicle  was  hard,  and  in  the  left  lobe  of  the  prostate  was  a 
large,  hard  nodule.  Tubercle  bacilli  found  in  the  urine.  Cystoscope  sh(#fed  a  cystitis 
without  definite  tubercles.  During  six  months  tuberculin  was  given.  Dosage,  -^-^^  to 
■sJn  ii^g-  He  gained  weight;  there  was  no  blood  in  his  urine  since  the  early  part  of  the 
treatment.     Micturition  less  frequent. 

A  second  case  for  four  months  urinated  every  ten  minutes  and  was  incontinent  at  night. 
Urine  thick  and  milky,  prostate  and  seminal  vesicle  affected.  After  four  months  there  was 
a  gain  of  weight,  lessened  pain,  urination  every  one  and  a  half  hours  during  the  day, 
every  two  hours  at  night.  After  twenty-one  months'  treatment  urination'  was  every  three 
hours  and  twice  at  night,  still  milky.  At  the  end  of  twenty-eight  months'  treatment  the 
urine  was  clear,  frequency  every  three  hours  in  the  day  time,  once  at  night. 

The  case  "  F.  G."  will  be  here  continued  as  one  of  tuberculous  cystitis  ' 
with  secondary  testicular  involvement: 

Beginning  October  7,  1908,  tuberculin  R.  was  injected  once  a  week,  initial  dosage 
2o:56o  "^S-  (bacillary  substance),  the  second  j^^^  mg.,  the  third  —^^  mg.,  the  latter 
repeated  weekly  until  December  22,  when  it  was  increased  sHghtly  to  ^ijVtj  mg.  After 
the  pus  was  aspirated  from  the  testicle,  a  sinus  continued  to  discharge  until  the  last 
of  December.  The  testicle  gradually  lessened  in  size,  and  the  epididymis  could  be  felt 
as  a  somewhat  enlarged,  hard  mass.  After  the  first  four  doses  of  tuberculin,  micturition 
became  less  frequent  (for  several  years  it  had  averaged  every  two  or  three  hours).  On 
December  22,  1908,  after  about  three  months'  treatment,  the  patient  stated  that  for  the  past 


GENITAL   TUBERCULOSIS  759 

week  he  had  several  times  held  his  urine  seven  hours  without  much  discomfort,  and  had 
not  been  up  at  night  to  micturate  for  some  time.  June  15,  1909,  the  dosage  had  reached 
jsViT  mg.  T.  R.  Urination  every  four  or  five  hours  and  not  at  aU  at  night.  August  3, 
tubercuhn  B.  E.  was  substituted  for  T.  R.,  inasmuch  as  results  in  other  cases  appeared  to 
be  superior  than  those  obtained  by  the  use  of  T.  R.  Initial  dose  ^  mg.  December 
24,  1909,  dosage  had  reached  Tt?tr?r  mg.  B.  E.,  and  the  last  dose,  March  4,  1910,  was  5-J5  mg. 

The  testicle  is  now  of  practically  normal  size,  the  epididymis  hard,  but  smaller  than  at 
first,  micturition  three  or  four  times  a  day,  never  at  night;  pain  after  micturition,  as  ex- 
perienced at  first,  has  almost  disappeared;  no  blood  in  the  urine  since  treatment  was  begun; 
weight  about  as  usual;  general  condition  excellent;  subjectively  and  objectively  perfectly 
well;  has  been  able  to  attend  to  business  from  the  start  of  treatment  as  he  had  previously, 
but  with  less  discomfort.  He  has  received  no  local  or  general  treatment  other  than  tuber- 
culin and  advice  as  to  hygiene. 

There  has  been  no  suspicion  of  constitutional  or  focal  reaction  following  injection  of 
vaccine. 

This  case  is  of  interest  in  the  matter  of  diagnosis.  The  finding  of 
tuberculous  ulceration  in  the  bladder  in  1904  indicates  that  the  bladder 
symptoms,  extending  over  from  five  to  ten  years,  were  within  reasonable 
probability  due  to  a  condition  of  tuberculous  cystitis;  the  testicular  in- 
volvement, which  occurred  four  years  after  the  ulcerations  were  found, 
and  proved  to  be  tuberculous  by  animal  inoculation,  confirms  the  ac- 
curacy of  the  cystoscopic  diagnosis.  - 

The  case  is  further  valuable  as  indicating  the  efficiency  of  tuberculin 
so  far  as  indications  may  be  obtained  from  the  study  of  any  one  case. 
The  symptoms  had  gradually  gotten  worse  over  a  long  period  previous 
to  the  beginning  of  tuberculin  treatment,  and  the  involvement  of  the 
testicle  came  as  evidence  of  unfavorable  progression  of  the  tuberculous 
process.  The  improvement  associated  with  the  exhibition  of  tuberculin 
may  not  only  be  taken  as  evidence  of  its  efficiency  in  cystitis,  but  also 
in  an  early  tuberculous  process  in  the  epididymis. 

The  outcome  of  the  case  also  shows  that  tuberculin  may  be  given 
successfully  without  the  production  of  any  symptoms  of  intolerance  of 
either  a  general  or  a  local  nature. 

The  question  of  when  to  stop  tuberculin  treatment  in  a  case  of  this 
kind  can  be  determined  only  by  the  method  of  trial  and  error.  The 
writer  proposes  to  inoculate  a  guinea-pig  with  the  centrifugalized  sedi- 
ment of  the  urine.  If  bacilli  are  to  be  found  in  the  urine,  the  treatment 
will  be  continued;  if  not  found,  tuberculin  will  be  stopped  for  a  month  or 
two  and  the  patient  kept  under  careful  observation.  Tuberculin  will  be 
started  again  if  increased  frequency  of  micturition,  pain,  or  other  symp- 
toms of  cystitis  develop. 

Tuberculosis  of  the  Genital  System. — The  chief  danger  of 
tuberculous  infection  of  the  genital  system  is  that  it  may  infect  the 
bladder.     Walker  {loc.  cit.)  considers  the  onset  of  cystitis  to  indicate 


760  THERAPEUTIC   IMMUNIZATION    AND    VACCINE    THERAPY 

extirpation,  if  possible,  of  the  organ  involved,  but  otherwise  does  not 
make  use  of  extensive  operative  procedures,  this  because  of  the  tendency 
of  these  lesions  to  contract  and  become  walled  off  as  a  result  of  the 
benefit  of  tuberculin  and  general  hygienic  measures. 

He  reports  a  case  of  tuberculous  epididymitis,  prostatitis,  and  vesicu- 
litis, in  which  decided  improvement  took  place  after  four  years'  treatment. 
The  lesion  in  the  epididymis  in  this  case  was  of  nineteen  years'  duration. 

Jones  {loc.  cit.)  reports  the  following  cases  of  tuberculous  testicle 
treated  in  Wright's  clinic — 3  cases  w^ere  cured,  2  "much  better,"  2 
"better,"  and  2  doubtful  as  to  the  result. 

Jones  sums  up  34  cases  of  genito-urinary  tuberculosis  treated  with 
tuberculin  in  Wright's  clinic  as  follows :  The  results  would  indicate  that 
great  improvement  may  be  obtained  in  3  out  of  7  cases,  and  slight  im- 
provement in  2  more  cases;  treatment  may  last  a  year  or  more.  There 
were  secondary  infections  in  one-half  the  cases. 

Genito-urinary  Tuberculosis  Associated  with  Tubercu- 
losis Klsewhere. — If  the  complicating  tuberculous  lesion  is  other 
than  pulmonary,  there  is  no  contraindication  to  the  use  of  tuberculin  in 
the  dosage  which  consideration  of  the  genito-urinary  condition  would 
indicate. 

If  there  is  -an  active  pulmonary  lesion,  the  dosage  of  tuberculin  must 
be  modified  according  to  the  special  requirements  for  treatment  of  a  case 
of  the  pulmonary  type.  If  there  is  pulmonary  involvement  of  a  more  or 
less  inactive  character,  tuberculin  may  be  guardedly  given.  We  must, 
at  first,  insist  that  the  patient  be  kept  quiet  during  the  twenty-four 
hours  after  inoculation,  in  order  to  eliminate  the  possibility  of  superim- 
posing an  autoinoculation  upon  the  inoculation  already  given,  and  thus 
avoid  what  might  constitute  a  toxic  dose  of  tuberculin. 

Tuberculin  Treatment 
There  is  no  form  of  tuberculosis,  except  the  pulmonary,  which 
requires  more  careful  attention  to  dosage  than  renal  tuberculosis.  In 
febrile  cases  we  are  dealing  with  autoinoculation.  Extremely  minute 
doses,  of  course,  must  be  given.  The  initial  dose  may  be  ^^q  mg. 
(B.  E.  solid  substance)  or  less,  repeated  in  from  five  to  ten  days  for  several 
inoculations,  when  it  may  be  increased  to  ^qqq  mg.  The  next  gradation 
will  be  to  3o\)ob'  ^-nd  hereafter  the  increase  must  be  more  gradual,  using 
several  doses  of  gsiob'  20;^  ^^"^  isWo  before  any  further  increase. 
The  safest  method  of  giving  tuberculin  is  to  bear  in  mind  that  the  aim 
should  always  be  to  fall  short  of  the  production  of  clinical  symptoms. 
That  this  will  be  in  some  cases  impossible  at  some  stage  of  the  treatment 


TUBERCULIN  TREATMENT  761 

is  evident.  We  have  in  the  cHnical  symptoms  a  guide  which  indicates 
when  any  dose  is  too  large.  There  may  be  rise  in  temperature,  increased 
frequency  in  micturition,  increased  pain  or  tenderness,  headache, 
malaise,  nausea,  etc.,  during  the  twenty-four  hours  after  inoculation, 
which  are  known  to  be  correlated  with  any  marked  reduction  in  the  op- 
sonic index.  If  such  symptoms  occur,  we  should  always  await  spon- 
taneous improvement  before  again  inoculating,  and  at  the  same  time  give 
a  considerably  smaller  dosage.  We  must  use  greater  care  in  further 
increase  of  dosage  as  the  treatment  progresses. 

In  afebrile  cases,  in  the  absence  of  subjective  evidence  which  indi- 
cates that  the  antibacterial  resistance  is  being  unnecessarily  lowered  by 
the  dosage  of  tuberculin  used,  we  may  have  positive  evidence  that  the 
tuberculin  is  doing  good  in  the  sense  of  well-being  that  the  patients 
frequently  experience  for  several  days  after  each  inoculation. 

Where  it  is  impossible  to  observe  any  local  changes,  as  in  tubercu- 
losis of  the  Iddney  or  in  the  seminal  vesicle,  prostate,  or  testicle,  following 
single  inoculations,  when  there  is  no  temperature,  we  can  begin  with  the 
usual  minimal  dose,  and  gradually  increase  at  about  the  same  pace  which 
would  be  used  in  the  case  of  bladder  tuberculosis  when  signs  would 
manifest  themselves  if  the  dosage  were  too  large.  In  the  same  way, 
based  on  experience  in  treating  cases  of  this  type,  using  the  opsonic  index 
as  a  guide,  we  are  able  to  obtain  a  scheme  which,  if  used  consistently,, 
will  gradually  promote  tolerance  to  tuberculin  by  a  very  gradual  increase 
in  dosage,  and  at  the  same  time  will  not  provoke  any  extended  period  of 
lowered  opsonic  power  with  its  attendant  lack  in  progress  or  retrogres- 
sion which  may  be  associated  with  a  series  of  prolonged  negative  phases. 

The  danger  of  producing  constitutional  disturbances  following  in- 
oculation in  cases  of  extensive  tuberculosis  of  soft  tissues,  such  as  we  are 
here  dealing  with,  is  much  greater  than  the  danger  from  such  reactions 
which  may  be  produced  in  glandular  cases.  Severe  constitutional  symp- 
toms, following  inoculation  with  tuberculin,  mean  nothing  else  than  the 
presence  in  the  blood  of  living  bacilli  and  poisons,  and  are  associated  with 
a  period  of  diminished  tuberculotropic  power  of  the  blood-stream. 
Dissemination  of  bacteria  with  the  blood-stream  at  such  a  period  cannot 
be  anything  but  dangerous  to  the  patient,  not  only  from  the  standpoint 
of  the  possibility  of  the  development  of  new  foci  elsewhere,  but  also 
through  the  extension  of  the  process  locally,  when  the  local  and  general 
barriers  of  resistance  are  temporarily  partially  broken  down.  If  we 
take  the  signs  of  intolerance  to  tuberculin  as  a  guide  for  dosage,  we  shall 
have  no  guide  unless  intolerance  is  produced.  That  repeated  consti- 
tutional disturbances  following  the  inoculation  are  consistent  with  more 


762  THERAPEUTIC   IMMUNIZATION  AND   VACCINE   THERAPY 

or  less  rapid  recovery  in  a  large  number  of  cases  is  well  known.  That 
the  use  of  large  doses  of  tuberculin  with  production  of  constitutional 
reactions  has  been  repeatedly  followed  by  disaster  is  quite  as  well  known. 
It  no  doubt  takes  a  somewhat  longer  course  of  treatment  to  arrive  at 
tolerance  to  the  same  amount  of  tuberculin  if  we  use  the  opsonic  method 
of  treatment  than  when  the  clinical  method  is  used,  but,  theoretically 
and  practically,  there  is  no  reason  to  think  that  the  results  of  treatment 
will  be  less  good  if  the  same  dose  is  finally  arrived  at.  By  the  opsonic 
method  we  arrive  at  the  large  doses  only  after  a  considerable  space  of 
time,  and  during  this  time  we  have  produced  no  periods  of  constitutional 
disturbance  and  attending  dangers.  The  largest  dose  of  tuberculin  that 
the  writer  is  giving  in  genito-urinary  cases  is  ~  mg.  B.  E.  after  two  years' 
treatment. 

Extirpation  of  tuberculous  organs  in  the  genito-urinary  system  is, 
in  the  majority  of  cases,  palliative,  because  the  process  is  apt  to  involve 
other  tissues  that  cannot  be  removed.  These  cases  are  rendered  diffi- 
cult and  often  impossible  as  surgical  problems  because  of  the  many 
avenues  for  extension  of  the  process;  because,  in  the  case  of  the  kidney, 
the  proper  functioning  is  interfered  with;  where  the  ureter  is  involved, 
it  may  become  occluded  and  render  useless  the  corresponding  kidney; 
where  symptoms  of  cystitis  are  intense,  surgery  may  offer  no  relief. 

There  is  no  doubt  that  some  patients  recover  after  removal  of  some 
seriously  involved  organ  and  that  the  body  is,  by  its  removal,  enabled  to 
hold  in  check  lesions  elsewhere.  But  we  know  that  it  is  through  the 
specific  antibacterial  power  of  the  blood  fluids  and  through  cellular  re- 
action in  walling  off  the  lesions  that  this  takes  place.  We  know  that 
the  blood-stream  itself  is,  in  the  vast  majority  of  cases,  deficient  in  tuber- 
culotropic  power,  and  have  seen  the  reason  for  this  in  the  segregation 
of  these  foci  from  the  circulation  and  the  consequent  lack  of  effective 
bacterial  stimulus  to  induce  the  formation  of  a  sufficiency  of  tuberculo- 
tropic  substances.  It  does  not  seem  an  irrational  procedure  to  make 
use  of  an  agent,  tuberculin,  to  furnish  an  artificial  stimulus  to  the  im- 
munizing mechanism  when  it  gives  every  evidence  of  being  in  default 
for  lack  of  this  stimulus.  In  fact,  the  knowledge  that  it  is  possible  to 
increase  the  power  of  the  blood-stream  to  destroy  tubercle  bacilli,  and 
thus  better  safeguard  the  rest  of  the  body  and,  perhaps,  prevent  further 
extension  of  lesions  already  under  way,  would  appear  to  render  the  use 
of  tuberculin  imperative  when  operative  procedures  have  accomplished 
all  that  is  to  be  expected  or  when  they  are  contra-indicated.  Clinical 
evidence  derived  from  the  treatment  of  other  localized  infections  with 
tuberculin  is  overwhelmingly  in  support  of  this  view. 


NEW   METHODS    FOR   PREPARATION   OF    VACCINES  763 

It  has  been  the  unfortunate  custom  in  medicine  to  base  on  briUiant 
results  achieved  by  new  methods  in  certain  types  of  infection  extra^'a- 
gant  expectations  as  to  their  efficiency  in  others.  That  it  is  unreason- 
able to  anticipate  that  masses  of  tuberculous  tissue  should  suddenly  melt 
away  under  tuberculin  treatment  should  be  evident  from  consideration 
of  the  conditions  in  tuberculous  foci.  We  cannot  expect  the  leukocytes 
or  antibacterial  substances  to  have  any  effect  upon  bacteria  that  they 
cannot  reach.  In  fact,  clinically,  tuberculin  may  not  appear  to  reduce 
the  size  of  a  tuberculous  prostate  or  seminal  vesicle  to  a  marked  degree, 
even  though  given  for  several  years.  It  may  be  reasonably  assumed, 
however,  that  with  a  blood-stream  high  in  protective  substances  the 
danger  of  extension  of  the  tuberculous  process  will  be  lessened.  On 
the  other  hand,  in  tuberculous  conditions  of  mucous  membranes,  as  that 
of  the  bladder,  we  should  anticipate  more  rapid  disappearance  of  lesions, 
and  this  appears  clinically  to  be  a  fact. 

Theoretically  and  practically,  the  indications  for  the  use  of  vaccine 
in  chronic  localized  infections,  of  tuberculin  in  chronic  localized  tuber- 
culosis, when  surgical  conditions  have  been  efficiently  met  and  cure  is  not 
forthcoming,  are  insistent  and  essential  in  a  degree  no  less  than  the  sur- 
gical procedure  as  leading  to  the  immunization  and  cure  of  the  patient. 

NEW  METHODS   OF  KILLING  BACTERIA    FOR  VACCINES— THE    USE 
OF   LIVING   VACCINES 

There  is  considerable  evidence  that  vaccines  composed  of  bacteria 
killed  by  heat  are  not  so  efficient,  so  far  as  their  vaccinating  qual- 
ities are  concerned,  as  those  killed  by  some  other  methods.  It  ap- 
pears that  heat  in  some  manner  modifies  the  particular  toxic  sub- 
stances contained  in  the  bacterial  cell,  in  such  a  manner  as  to  render 
them  less  efficient  in  inducing  the  formation  of  corresponding  specific 
protective  substances.  It  would  be  desirable,  if  possible,  to  make  use  of 
bacterial  protoplasm  as  vaccine  without  subjecting  it  to  the  modification 
of  heat.  Unquestionably,  a  much  higher  degree  of  immunity  can  be 
produced  against  tuberculosis  in  laboratory  animals  by  means  of  living 
cultures  than  by  means  of  killed  cultures. 

Trudeau,  referred  to  by  Webb  and  Williams/  states  that  in  protective  inocu- 
lation against  tuberculosis  it  was  only  when  he  began  to  use  living  cultures 
as  inocula  that  he  met  encouraging  results,  and  that  his  experience  indicates 
that  the  living  germ  is  essential  to  what  success  has  been  obtained  in  the  pro- 
duction of  artihcial  immunity  against  tuberculosis  in  animals. 

Neufeld,  referred  to  by  the  same  writers,  abandoned  attempts  to  immunize 

^  Jour.  Med.  Research,  January,  1909,  p.  4. 


764  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

animals  with  toxins  and  dead  tubercle  bacilli  after  thorough  trial,  but  was 
able  to  produce  immunity  by  living,  but  attenuated,  tubercle  bacilli  of  both 
human  and  bovine  t}^e.  He  usually  preceded  the  injection  of  living  organ- 
isms by  an  injection  of  pulverized  bacilli. 

Theobald  Smith^  failed  to  produce  any  degree  of  immunity  to  tubercu- 
losis, using  bovine  cultures  killed  at  60°  C,  by  injecting  five  to  ten  times  the 
amount  of  living  human  tubercle  bacilli  which  had  conferred  immunity  upon 
cattle  to  the  bovine  bacillus. 

It  would,  therefore,  appear  that  immunity  to  tuberculosis  could  be 
much  better  produced  if  it  were  possible  to  use  living  organisms.  The 
work  of  Patterson  and  Inman  -  records  the  treatment  of  pulmonary 
tuberculosis  by  means  of  induced  autoinoculation  as  a  result  of  carefully 
graduated  exercise.  They  proved  that  autoinoculation  took  place  after 
exercise  by  means  of  variations  in  the  opsonic  power  of  the  blood  follow- 
ing such  exercise.  There  was  no  explanation  other  than  that  these 
autoinoculations  consisted  of  Hving  tubercle  bacilli.  Results  which 
Patterson  has  achieved  by  application  of  this  method  would  appear  to 
be  very  much  superior  to  those  obtained  in  the  treatment  of  pulmonary 
tuberculosis  in  human  beings  by  any  other  method. 

Having  at  their  disposal  that  most  remarkable  and  ingenious  tech- 
nique devised  by  Barber,  whereby  he  is  able  to  isolate  a  single  living 
tubercle  bacillus  or  other  micro-organism,  and  inject  the  same  subcutane- 
ously,  they  (Webb,  Williams,  and  Barber)  were  enabled  to  inoculate 
patients  with  as  many  or  as  few  living  bacilli  as  desired,  with  the  idea 
of  securing  a  better  therapeutic  effect  than  would  be  expected  from 
ordinary  tuberculin. 

They  report  the  inoculation  of  five  tuberculous  men.  In  the  first  case  one 
tubercle  bacillus  was  injected  subcutaneously.  Sixty  days  later  there  was 
no  trace  of  the  inoculation  site.  The  second  case  was  given  one  bacillus,  and 
six  days  later  five  more.  After  sixty  days  there  was  no  evidence  of  infection 
at  either  site  of  inoculation.  The  third  case,  one  of  extensive  pulmonary 
tuberculosis,  had  been  treated  by  usual  measures  without  beneficial  result. 
Following  the  first  inoculation  of  one  bacillus,  subsequent  inoculations  were 
given,  at  intervals  of  four  to  seven  days,  of  from  5  up  to  500  bacilli.  After 
the  ninth  dose,  one  of  250  bacteria,  the  temperature  fell  to  normal  and  re- 
mained there.  They  worked  out  the  effect  upon  the  opsonic  index,  and 
found  that  inoculations  were  followed  by  rise  above  normal.  The  process 
was  arrested.  The  fourth  case  was  acute  pulmonary  tuberculosis,  first  inocu- 
lation of  50  bacilli.  They  finally  reached  500.  With  the  sixth  inoculation 
fever  disappeared  and  cough  improved.     After  seven  weeks  patient  was  able 

^  Jour.  Med.  Research,  June,  1908. 
^  Lancet,  January  25,  1908. 


VACCINE    COMPOSED   OF   LIVING    ORGANISMS  765 

to  do  light  work.    After  twenty-two  inoculati@ns,  the  last  being  500,  the 
patient  was  discharged  as  cured. 

The  last  case,  one  of  extensive  pulmonary  tuberculosis,  had  had  tuberculin 
treatment  for  two  years  and  sanatorium  treatment  for  three  years  without 
distinct  benefit.  From  an  injection  of  one  tubercle  bacillus  a  dosage  of  500 
living  bacilli  was  reached.  The  patient  felt  better,  but  general  improvement 
was  not  demonstrated;  no  apparent  harm  was  done,  no  local  or  general 
reactions,  and  no  lesions  were  produced  at  the  inoculation  sites. 

It  would  appear,  from  the  evidence  cited,  first,  that  li^'ing  tubercle 
bacilli  possess  a  greater  power  of  inducing  protective  response  than 
killed  bacilli  or  tuberculin;  second,  that  in  the  cases  cited,  li\-ing  tubercle 
bacilli  were  injected  into  human  beings  without  apparent  harm  being 
done — on  the  contrary,  with  clearly  beneficial  results. 

Castellani  ^  found  that  much  greater  protective  response  resulted 
in  rabbits  and  monkeys  from  the  inoculation  of  a  single  dose  of  live 
tj'phoid  vaccine  than  could  be  obtained  from  the  same  dose  of  killed 
culture.  He  found  that  a  larger  amount  of  agglutinins  and  immune 
bodies  were  produced  in  the  former  than  in  the  latter  method. 

He  quotes  Haffkine  in  regard  to  cholera  vaccination,  and  Strong  and  Kolle 
in  regard  to  plague  vaccination,  to  the  effect  that  the  degree  of  immunization 
obtained  by  using  virulent  live  cultures  is  far  greater  than  that  obtained  by 
using  dead  cultures.  In  protective  inoculation  against  typhoid,  he  used 
living  cultures,  modified  by  heating  in  a  water-bath  at  50°  C,  for  one  hour. 
Such  a  vaccine  is  alive,  as  proved  by  inoculating  agar  tubes.  He  inoculated 
90  individuals  with  such  a  culture  during  a  period  of  four  years.  Although 
living  in  a  typhoid-infested  district,  none  of  them  developed  the  disease. 
Among  106  cases  inoculated  according  to  Wright's  method,  using  killed 
cultures,  the  most  recent  being  26  cases  being  inoculated  three  months  before 
this  paper  was  published  (March,  1909),  two  developed  typhoid  fever,  but  no 
deaths  occurred.  In  220  cases  he  combined  both  methods,  using  for  an 
initial  dose  killed  cultures,  and  for  a  second  his  live  vaccine.  One  hundred 
and  fifty  were  inoculated  eighteen  months,  45  one  year,  and  25  three  months 
before  publishing,  and  none  had  developed  the  disease  at  this  time.  The  effect 
of  the  vaccine  upon  the  patients  was  more  marked  than  that  produced  by 
killed  cultures,  hut  in  no  case  did  typhoid  develop  and  in  none  were  there  any 
untoward  results.  There  were  temperature  and  malaise  for  twenty-four  hours 
or  less,  but  the  individuals  were  able  to  carry  on  their  usual  work  in  spite  of  it. 

These  experiments  are  of  great  value,  in  that  they  indicate  that 
living  organisms  modified  by  heating,  or  attenuated  organisms  intro- 
duced in  small  and  accurately  measured  numbers,  may  produce  no 

*  Lancet,  August  21,  1909. 


766  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

harmful  effect.  The  superior  vaccinating  qualities  of  unaltered  bacterial 
protoplasm  being  generally  accepted,  it  may  be  that  further  experience 
may  justify  the  use  of  such  vaccine  in  some  cases.  It  does  not  appear, 
however,  that  we  have  reached  the  stage  that  would  justify  the  use  of 
anything  but  killed  bacteria  in  the  general  practice  of  medicine. 

We  must,  nevertheless,  bear  in  mind  the  work  of  Patterson  in 
treating  pulmonary  tuberculosis  by  autoinoculation,  which  is  really  a 
method  which  makes  use  of  living  vaccines.  We  must  further  realize 
that,  in  the  application  of  Bier's  passive  hyperemia  in  localized  infec- 
tions, we  must  attribute  the  beneficial  results  to  the  entrance  of  autoinocu- 
lating  numbers  of  bacteria  into  the  blood.  While  there  is  no  justification 
at  present  for  our  assuming  the  risk  associated  with  inoculation  of  living 
even  though  attenuated  bacteria,  except  perhaps  in  such  apparently 
hopeless  cases  as  have  been  cited,  we  have  excellent  reason  for  seeking 
methods  of  killing  bacteria  which  may  be  calculated  not  to  alter  the 
vaccinating  qualities  of  their  protoplasm. 

We  have  good  evidence,  in  the  work  of  Weaver  and  Tunncliffe,^ 
that  a  streptococcic  vaccine,  composed  of  organisms  killed  by  a  solu- 
tion of  galactose,  has  superior  vaccinating  qualities  to  the  same  killed 
by  heat.  By  inoculating  animals  they  compared  the  immunizing  effect 
of  vaccines  prepared  by  these  two  methods.  Their  experience  in  using 
streptococcic  vaccine,  prepared  in  the  ordinary  manner  by  heating,  is 
consistent  with  that  obtained  by  many  workers,  in  that  they  found  that 
the  results  were  not  so  good  as  had  been  obtained  in  the  use  of  vaccines 
of  other  types  of  organisms. 

Their  technique  was  as  follows:  They  washed  off  in  a  sterile  25  per  cent, 
galactose  solution  a  twenty-four-hour  growth  of  streptococcus  on  blood-agar, 
2  cc.  of  the  solution  being  employed  for  each  agar  slant.  This  suspension 
of  bacteria  in  galactose  solution  was  incubated  for  from  forty-eight  to  seventy- 
two  hours,  and  during  this  period  was  shaken  several  times.  The  emulsion 
obtained  from  each  agar  tube  was  centrifugalized,  the  supernatant  fluid 
pipeted  off,  and  the  residue  desiccated  in  vacuum  over  calcium  chlorid  at 
room  temperature  and  sealed.  Usually  the  bacteria  were  found  to  have  been 
killed  in  twenty-four  hours.  One  strain  of  streptococcus  was  not  killed  in 
forty-eight  hours,  but  was  sterile  after  seventy-two  hours.  The  killed  organ- 
isms were  then  suspended  in  2  or  3  cc.  of  sterile  normal  salt  solution. 
The  vaccines  which  they  used  for  comparison  were  prepared  in  the 
usual  manner,  and  killed  by  thirty  minutes'  exposure  to  a  temperature  of 
60°  C.  They  found  that  galactose-killed  streptococci  induced  in  rabbits 
more  or  less  immunity  to  the  living  streptococcus.     It  required  five  to  seven 

^  Jour.  Infec.  Dis.,  Dec.  18,  1908. 


GALACTOSE-KILLED    VACCINE  767 

days  after  the  inoculation  for  this  immunity  to  appear.  Protection  afforded 
by  two  doses  was  greater  than  that  of  a  single  dose.  They  found  that  the 
opsonic  index  was  elevated  after  injections  and  followed  a  more  or  less  regular 
course.  The  negative  phase  was  more  marked  after  the  first  dose  than  after 
the  second.  The  index  was  usually  highest  on  the  second  or  the  third,  fourth, 
and  fifth  days  after  injection.  The  larger  the  dose,  the  higher  the  indices. 
Two  guinea-pigs  were  protected,  each  by  the  injection  of  500,000,000  galactose- 
killed  streptococci,  and  six  days  later  each  was  inoculated  with  a  hving  strepto- 
coccus culture  intraperitoneally.  Both  were  well  a  month  after  inoculation. 
The  control,  unprotected  animal  died  in  eighteen  hours.  As  a  part  of  the 
same  experiment,  guinea-pigs  were  inoculated  b}'  the  same  doses  of  heat- 
killed  bacteria,  and  after  the  same  period  were  inoculated  with  a  living  broth 
culture  intraperitoneally.     All  these  animals  died. 

Again,  one  rabbit  was  inoculated  with  500,000,000  galactose-killed  strepto- 
cocci, four  days  later  the  same  dose  was  repeated,  and  after  ten  days  3  cc.  of 
a  twenty-four-hour  living  broth  culture  of  streptococcus  was  injected  intra- 
peritoneally. The  rabbit  did  not  become  sick  and  was  well  a  month  later. 
A  second  rabbit,  inoculated  in  the  same  manner,  but  with  heat-killed  strepto- 
cocci, and  later  injected  with  the  same  amount  of  a  living  streptococcus  culture 
intraperitoneally,  died  twelve  hours  after  inoculation. 

The  advantage  of  the  galactose-killed  vaccine  over  that'  killed  by 
heat  appears  to  be  perfectly  definite.  In  one  of  the  rabbits  treated  by 
galactose-killed  vaccine  the  opsonic  index  six  days  after  inoculation  was 
6.  In  the  rabbit  of  the  same  group,  treated  by  heat-killed  vaccine,  the 
opsonic  index  remained  approximately  i.^ 

They  conclude  that  subcutaneous  injections  of  galactose-killed 
streptococci  all  produce  definite  phenomena,  in  the  fact  of  a  very  great 
rise  in  the  opsonin,  as  indicated  by  the  increased  phagocytic  power; 
that  hand  in  hand  with  this  rise  in  opsonic  power  the  animals  developed 

^  The  clinical  results  in  the  use  of  heat -killed  streptococci  would  more  or  less  confirm 
this  view.  Certainly  the  use  of  streptococcus  vaccine  is  not  commonly  followed  by  the 
consistently  good  effects  seen  in  the  case  of  vaccines  prepared  from  other  organisms.  A 
reasonable  explanation  is  that  particular  endotoxins  of  the  streptococcus  are  much  more 
easily  altered  by  heat  than  those  of  some  other  bacteria  commonly  and  successfully  used. 
In  general  accord  with  these  observations,  as  to  the  comparative  inefficiency  of  strep- 
tococcus vaccine  when  killed  by  exposure  to  a  temperature  of  60°  C.  for  one  hour,  is  the 
experience  of  Leary  (Boston  Med.  and  Surg.  Jour.,  1909,  clxi,  716).  He  states  that 
"  clinical  results  from  the  use  of  such  vaccine  were  unsatisfactory."  Consequently,  he 
shortened  the  time  of  sterilization  to  fifteen  minutes  at  60°  C.  and  obtained  better 
results.  "  Positive  cultures  of  the  streptococcus  may  be  obtained  from  the  suspension  " 
at  the  end  of  the  exposure.  He  adds  \  per  cent,  carbolic  acid  after  heating.  He  states 
that  "  this  small  amount  of  carbolic  acid  .  .  .  results  in  killing  or  further  attenuation 
of  the  organism,  so  that  infection  is  not  possible.  We  have  now  used  such  vaccine  on 
several  hundred  cases  without  any  infections  and  with  results  markedly  superior  to  those 
obtain';d  when  Wright's  rule  was  followed." 


768  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

a  considerable  degree  of  immunity  to  living  virulent  streptococci,  of 
sufficient  degree  to  protect  the  animal  against  doses  of  living  culture 
that  killed  normal  animals.  The  protection  may  be  complete,  or  it  may 
delay  and  modify  the  infection. 

In.  marked  contrast  are  the  effects  of  the  injection  of  heat-killed 
streptococci,  in  that  they  did  not  produce  any  pronounced  increase  in 
opsonin;  the  animals  thus  treated,  when  injected  with  living  cultures, 
later  appear  to  have  had  even  less  resistance  than  normal  animals. 
They  report  excellent  results  in  the  treatment  of  patients.  First,  a  case 
of  suppurative  otitis  media  and  mastoiditis,  the  second  of  chronic  ery- 
sipelas. They  conclude  that,  in  view  of  the  results  in  attempts  in  pro- 
tecting rabbits  against  virulent  streptococci  by  heat-killed  vaccine,  it 
is  doubtful  if  one  gains  any  advantage  in  the  therapeutic  use  of  strep- 
tococci killed  by  heat. 

DOSAGE  TABLE 

The  vaccinating  quaHties  of  different  vaccines,  composed  of  the  same 
species  of  organisms,  but  of  different  derivations,  may  vary  to  a  consider- 
able degree.  The  dosage  of  one  may  necessarily  be  twice  that  of  the 
other,  to  produce  the  same  immunizing  response.  Hence,  numerical 
standardization,  although  it  must  be  accurate,  is  only  tentative.  The 
final  standardization  is  that  derived  from  clinical  use. 

Dosage  of  tubercuhn  B.  E.  and  T.  R.  is  based  on  content  of  each 
cubic  centimeter  of  the  original  solution  in  actual  bacterial  substances. 

The  following  table  represents  dosage  as  has  been  used  by  Wright 
at  St.  Mary's  Hospital,  London: 

Dosage   of   Vaccines 

Minimum.  Maximum.  Average. 

Tuberculin  R.  or  B.  E ^^  ^^ 

Staphylococcus 25  m.  looo  m.  250  m. 

Streptococcus i  m.  300  m.  10  m. 

Gonococcus ^  m.  10  m.  i  m. 

Pneumococcus i  m.  300  m.  10  m. 

Diplococcus  intracellularis  meningitidis 10  m.  100  m. 

Micrococcus  catarrhalis i  m.  300  m.  10  m. 

Micrococcus  neoformans lo  m.  50  m-  25  m. 

Bacillus  coli '2  m.  1000  m.  100  m. 

Bacillus  t)^hosus 5  rn- 

Bacillus  pyocyaneus > 2  m.  1000  m.  100  m. 

Bacillus  of    Friedlander 4  m.  8  m.,  6  m. 

B.  Typhosus  Protective  Inoculation^ 
First  dose,  loco  m. 
Ten  days  later,  2000  m. 

^  See  p.  770. 


INJECTION   OF   VACCINE 


769 


Fig.  263. — Inoculation. 
Withdrawing  vaccine  from  bottle  by  plunging  sterile  needle  through  rubber  cap. 


Fig.  264. — Inoculation. 
Sterilizing  point  of  injection  by  touching  skin  with  a  pledget  of  cotton  wet  with  pure  lysol. 


Fig.  265. — Inoculation. 
The  arm  is  grasped  so  tightly  that  the  skin  is  under  tension. 


49 


770  THERAPEUTIC   IMMUNIZATION   AND    VACCINE   THERAPY 

The  writer  has  varied  the  dosage  given  on  p.  768  in  his  own  practice: 
Initial  Dosage  (Febrile  Cases) 

Tuberculin  R.  or  B.  E TniTTino  '"^S-  i^  children; 

g^mg.  in  adults. 

Streptococcus 1,000,000  to    5,000,000. 

Gonococctis 1,000,000  to    5,000,000. 

Piieumococcus 1,000,000  to  10,000,000. 

Bacillus  coli 2,000,000  to  10,000,000. 

Bacillus  typhosus .- 5,000,000  to  10,000,000. 

Staphylococcus 20,000,000  to  50)0oo,ooo. 


1 


Initial  Dosage  (Afebrile  Cases) 

Tuherculin  R.  or  B.  E _^  to  ^^  mg. 

Staphylococcus 100,000,000  to  250,000,000. 

Streptococcus 10,000,000. 

Piieumococcus 10,000,000. 

Gonococcus 10,000,000. 

Bacillus  coli 10,000,000. 

Antityphoid  Inoculation. — An  attenuated  culture  is  desirable  as  a 
basis  for  vaccine.  One  that-has  grown  in  the  laboratory  for  a  long  time 
is  suitable.  Three  doses,  100,000,000,  200,000,000,  and  400,000,000  at 
six-  to  eight-day  intervals. 

Positive  agglutination  in  a  dilution  of  serum  i :  128  has  been  repeat- 
edly obtained  after  a  dosage  of  106,000,000.  Subjective  symptoms 
using  this  dosage  have  been  negligible  in  the  few  cases  treated. 


CHAPTER  LIII 

COLEY  SERUM  FOR  MALIGNANT  TUMORS 

Dr.  William  B,  Coley,  after  long  and  careful  experimentation, 
described  in  1891^  a  method  of  treatment  for  sarcoma  which  is  familiarly 
known  as  the  subcutaneous  treatment  with  Coley  toxins.  The  agent 
employed  is  a  filtrate  of  the  combined  toxins  of  the  streptococcus  of 
erysipelas  and  the  Bacillus  prodigiosus.  Its  use  was  suggested  by  the 
fact  that  certain  malignant  tumors,  which  had  been  partially  removed 
by  operation,  were  observed  to  be  at  least  temporarily  inhibited  if  in- 
oculated with  erysipelas.  In  the  original  cases  this  inoculation  was,  of 
course,  accidental.  Coley  determined  to  use  this  clinical  observation 
as  the  basis  for  accurate  treatment  wdth  small  but  continued  doses  of 
the  erysipelas  toxin,  and,  to  make  this  possible,  sought  to  procure  a 
filtrate  of  unvarying  strength.  This  he  has  succeeded  in  doing,  and 
has  made  it  more  effective  by  adding  a  toxin  of  the  Bacillus  prodigiosus. 
These  combined  toxins,  as  made  by  Dr.  Martha  Tracy  from  Dr.  Coley's 
directions,  are  much  more  powerful  than  the  original  liquid  or  the  prep- 
arations offered  by  manufacturing  chemists.  The  initial  dose  should 
never  be  more  than  ^  minim;  it  may  be  put  into  the  tumor  or 
under  the  skin  in  any  convenient  part  of  the  body;  it  is,  at  least 
theoretically,  safer  to  give  the  early  injections  away  from  the  growth, 
as  injections  given  into  the  tumor  mass  itself  maybe  absorbed  irregularly, 
either  slowly  or  very  rapidly,  and  it,  therefore,  seems  better  to  give  the 
early  injections  at  least  into  normal  tissues.  If  there  is  no  reaction 
following  the  initial  injection,  -h  m.inim  may  be  given  on  the  following 
day,  and  'the  amount  gradually  increased  on  successive  days  until  a 
reaction  is  obtained.  The  reaction  consists,  subjectively,  in  a  feeling  of 
malaise,  with  headache,  chill,  fever,  general  pain,  nausea,  and,  if  the 
dose  be  excessive,  vomiting  and  collapse,  and  the  objective  signs  of  rapid 
pulse,  small  in  volume,  temperature  elevation  to  103°  to  105°  F.,  sweating, 
all  the  signs  of  an  intense  intoxication.  Death  has  been  reported  in  one 
or  two  instances.  The  gradually  increasing  dose  will  ultimately  produce 
a  reaction  of  moderate  severity,  which  may  present  all  the  symptoms 
enumerated  or  emphasize  one  or  two  of  them  particularly;    after  a 

*  Ann.  Surg.,  1891,  xiv,  210. 

771 


772  COLEY    SERUM    FOR   MALIGNANT    TUMORS 

reaction,  one  or  two  days  should  intervene  before  another  injection  is 
made,  and  the  amount  should  be  only  very  slightly  increased.  Oc- 
casionally a  moderate  increase  of  the  amount  injected  may  make  a 
terrific  increase  in  the  character  of  the  reaction,  as  in  the  case  cited  below. 
The  object  should  be  to  produce  reactions  as  powerful  as  the  patient 
can  withstand  without  too  great  subsequent  prostration,  and  to  continue 
these  at  two-  or  three-day  intervals,  until  either  the  growth  begins  to 
disappear  or  it  becomes  obvious  that  toxins  will  not  affect  the  disease. 
In  successful  cases  the  treatment  may  continue  two  or  three  months,  and, 
after  an  interval  of  rest,  be  again  instituted  if  signs  of  the  disease  still 
remain  or  reappear. 

Results. — It  would  seem,  from  Coley's  paper,^  that  rather  more  than 
ID  per  cent,  of  otherwise  hopeless  cases  have  been  cured  subsequent  to 
this  treatment.  Among  the  cases  treated  immediately  under  Coley's 
observation  the  percentage  is  higher. 

It  seems  only  justice  to  the  patient  to  recommend  a  thorough  trial  of 
this  method  in  every  case  of  sarcoma  in  which  it  is  known  or  suspected 
that  operation  has  failed  to  remove  the  disease  in  toto;  and  in  every 
operative  case  in  which  there  is  recurrence  or  the  suspicion  of  recurrence. 
Operation  should  be  done  in  every  case  in  which  there  is  prospect  of 
removing  all  or  almost  all  of  the  growth  without  serious  danger  to  the 
patient's  life,  and  the  Coley  toxins  should  follov/.  Occasionally  a 
course  of  the  toxins  has  been  instituted  before  operation,  and  perhaps 
with  some  benefit,  but  it  should  never  be  prolonged  in  the  face  of  an 
advancing  disease.  It  would  seem  indisputable  that  some  cases,  other- 
wise certainly  and  rapidly  fatal,  have  been  restored  to  health  after  the 
thorough  use  of  Coley  toxin  and  without  other  medication  or  treatment. 

Fatal  Case. — Within  two  years  a  reputable  practitioner,  residing  in  the 
suburbs  of  Boston,  reported  (orally)  the  case  of  an  individual  past  middle  age. 
with  a  large  sarcoma,  upon  whom  the  toxin  treatment  was  to  be  used.  The 
first  dose  was  \  minim  of  the  toxins,  given  by  the  physician  himself.  Almost 
immediately  after  the  injection  the  patient  went  into  sudden  collapse,  and  in 
spite  of  all  efforts  died  within  a  few  minutes.     No  autopsy. 

A  patient  suffering  from  so-called  Hodgkin's  disease,  mth  extensively  en- 
larged cervical,  axillary,  and  inguinal  nodes,  was  being  treated  with  slowly 
increasing  doses  of  the  toxins.  Immediately  following  an  injection  of  less 
than  I  minim  more  than  the  previous  dose,  after  which  little  or  no  reaction 
occurred,  there  was  a  sudden  collapse,  with  extreme  weakness — pulse  i6o 
and  almost  imperceptible;  nausea  and  vomiting,  cold  sweat,  sighing  respira- 
tion, and  diarrhea.     This  improved  slowly,  but  left  the  patient  very  weak  for 

^Boston  Med.  Surg.  Jour.,  1908,  clviii,  175. 


COLEY  SERUM  FOR  SARCOMA  773 

forty-eight  hours.     It  is  fair  to  say  that  this  patient  was  one  in  whom  the 
normal  resistance  was  greatly  diminished. 

In  conclusion,  it  seems  certain  that  the  spindle-cell  sarcoma  is  most 
likely  to  be  benefited  by  the  toxins;  the  large  round-cell  to  a  lesser  degree, 
the  small  round-cell,  with  many  mitotic  figures,  least  of  all. 

Dr.  Leo  Loeb^  says,  "I  have  written  to  a  number  of  prominent  surgeons, 
asking  for  a  statement  concerning  their  experience  with  Coley's  fluid.  P'our- 
teen  of  these  surgeons  had  had  personal  experience  with  this  mode  of  treat- 
ment. The  majority  state,  without  giving  the  number  of  patients  treated, 
that  they  have  not  seen  any  successful  cases.  From  some  surgeons  I  obtained 
the  number  of  cases  treated,  and  the  result  was  as  follows:  Among  78  cases 
of  sarcoma,  in  4  cases  a  cure  was  obtained;  therefore,  in  not  quite  5  per  cent, 
of  the  cases  treated  a  positive  result  was  observed.  On  the  other  hand,  in 
a  number  of  cases  in  which  no  cure  was  obtained,  the  injection  of  the  toxins 
seemed  to  have  a  marked  weakening  influence  on  the  patient,  and  sometimes  it 
produced  a  sloughing  of  the  tumor. 

"  It  is,  therefore,  Hkely  that  the  treatment  of  inoperable  sarcoma  with  the 
4:oxins  of  streptococcus  and  Bacillus  prodigiosus  leads  to  a  cure  in  approxi- 
mately 4  to  9  per  cent,  of  cases,  and  some  results  obtained  so  far  suggest  that 
this  method  of  treatment  may  prove  of  value  as  a  postoperative  procedure  in 
diminishing  the  number  of  recurrences,  and  that  in  a  certain  number  of  cases 
it  might  limit  the  necessity  for  amputation  of  the  limb  in  cases  of  sarcoma  of 
the  long  bones.  As  to  its  mode  of  action,  nothing  definite  can  be  stated,  but 
it  is  likely  that  the  toxins  themselves,  as  well  as  the  local  and  general  reactions 
they  produce,  frequently  affect  the  life  of  the  sarcoma  cells  unfavorably." 
^  Jour.  Amer.  Med.  Assoc,  1910,  liv,  263. 


APPENDIX 

SOME  INVALID  AND  CONVALESCENT  FOOD  RECIPES 

Many  times  a  surgeon  is  asked,  "Doctor,  what  may  I  have  to  eat?" 
or,  "Doctor,  I  am  getting  so  tired  of  this,  or  that,  can't  you  let  me  have 
something  different?"  He  will  find  that,  in  the  long  run,  it  will  be 
an  asset  of  no  mean  value  to  be  able  to  direct  whoever  is  in  charge  in 
the  making  of  a  few  simple  and  tasty  dishes.  With  a  trained  nurse 
on  the  case,  he  can  usually  relegate  the  responsibility  in  this  matter  to 
her,  but  even  under  these  circumstances  it  is  sometimes  unwise  to 
allow  too  much  latitude  in  the  choice  and  construction  of  dishes,  and 
in  serious  cases  the  surgeon  should  know  exactly  what  the  patient  is 
getting  and  how  it  is  being  prepared.  It  is  for  the  purpose  of  supplying 
a  number  of  nutritious  and  appetizing  recipes,  simple  to  make,  and  of 
proved  value,  to  which  the  doctor  may  refer,  that  this  section  is  added. 

Apple -water. — Slice  into  a  pitcher  six  juicy  sour  apples.  Add  a  table- 
spoonful  of  sugar,  and  pour  over  them  a  quart  of  boiling  water.  Cover  closely 
until  cold,  then  strain.     Slightly  laxative. 

Arrowroot. — Mix  a  teaspoonful  of  Bermuda  arrowroot  with  4  teaspoon- 
fuls  of  cold  milk.  Stir  this  slowly  into  half  a  pint  of  boiling  water,  and  let  it 
simmer  for  five  minutes.  Keep  stirring  all  the  time,  to  pi  event  lumps  and 
keep  it  from  burning.  Add  half  a  teaspoonful  of  sugar,  a  pinch  of  salt,  and 
one  of  cinnamon,  if  desired.  (In  place  of  the  cinnamon,  half  a  teaspoonful 
of  brandy  may  be  used,  or  a  dozen  large  raisins  may  be  boiled  in  the  water. 
If  the  raisins  are  preferred,  they  should  be  stoned,  and  the  sugar  may  be 
omitted.) 

Corn-starch  or  rice-flour  gruel  is  made  in  the  same  way. 

Barley-water. — Wash  thoroughly  2  ounces  of  pearl  barley  in  cold 
water.  Add  2  quarts  of  boiling  water  and  boil  until  reduced  to  i  quart — or 
about  two  hours — stirring  frequently.  Strain,  add  the  juice  of  a  lemon  and 
sweeten.     For  infants  omit  the  lemon. 

Beef-essence. — Mince  finely  a  pound  of  lean,  juicy  beef  from  which 
all  the  fat  has  been  removed;  put  into  a  wide-mouthed  bottle  or  fruit-jar, 
and  cork  tightly.  Set  the  jar  into  a  kettle  of  cold  water  over  a  slow  fire,  bring 
the  water  to  a  boil,  and  let  it  boil  for  three  hours.  Strain  and  season  with  salt 
and  red  pepper. 
774 


SOME   INVALID   AND    CONVALESCENT   FOOD   RECIPES  775 

Beef-juice. — Place  ^  pound  of  lean,  juicy  beef  on  a  broiler  over  a  clear 
hot  fire,  and  scorch  each  side.  Press  out  the  juice  with  a  lemon-squeezer 
into  a  hot  cup,  add  salt,  and  serve  hot  with  toast  or  crackers. 

Beef-tea,  Peptonized.— To  ^  pound  of  raw  beef,  free  from  fat  and 
finely  minced,  add  10  gr.  of  pepsin  and  2  drops  of  hydrochloric  acid. 
Put  in  a  large  tumbler,  and  cover  with  cold  water.  Let  it  stand  for  two 
hours  at  a  temperature  of  90°  F.,  stirring  frequently.  Strain  and  serve  in 
a  red  glass,  ice  cold.  Peptonized  food  does. not  keep  well,  and  should  not 
be  used  more  than  twelve  hours  old. 

Beef-tea  with  Oatmeal. — Mix  a  tablespoonful  of  well-cooked  oatmeal 
with  two  of  boiling  water.  Add  a  cupful  of  strong  beef-tea,  and  bring  to  the 
boiling-point.  Salt  and  pepper  to  taste,  and  serve  with  toast  or  crackers. 
Rice  may  be  used  in  place  of  the  oatmeal. 

Broth,"  Chicken. — An  old  fowl  vdll  make  a  more  nutritious  broth  than  a 
young  chicken.  Skin,  cut  it  up,  and  break  the  bones  with  a  mallet.  Cover 
well  with  cold  water,  and  boil  slowly  for  three  or  four  hours.  Salt  to  taste. 
A  Uttle  rice  may  be  boiled  with  it,  if  desired. 

Broth,  Clam. — Take  3  large  clams,  washed  clean,  and  let  them  stand 
in  enough  boiling  water  to  cover  them  till  the  shells  begin  to  open.  Drain 
out  the  liquor,  add  an  equal  quantity  of  boiling  water,  a  teaspoonful  of  finely 
pulverized  cracker  crumbs,  a  little  butter,  and  salt  to  taste. 

Broth,  Mutton.- — Cut  up  fine  2  pounds  of  lean  mutton,  without  fat  or 
skin.  Add  a  tablespoonful  of  pearl  barley,  a  quart  of  cold  water,  and  a 
teaspoonful  of  salt.  Let  it  boil  slowly  for  two  hours.  If  rice  is  used  in  place 
of  the  barley,  it  will  not  need  to  be  put  in  until  half  an  hour  before  the  broth  is 
done. 

Broth,  Oyster. — Cut  into  small  pieces  a  pint  of  oysters;  put  them  into 
i  pint  of  cold  water,  and  let  them  simmer  gently  for  ten  minutes  over  a  slow 
fire.     Skim,  strain,  add  salt  and  pepper. 

Chocolate. — Scrape  fine  i  ounce  of  chocolate,  add  2  tablespoonfuls  of 
sugar  and  i  tablespoonful  of  hot  water;  stir  over  a  hot  fire  for  a  minute  or 
two  until  it  makes  a  smooth  paste,  then  pour  into  it  i  pint  of  boiUng  milk, 
mix  thoroughly  and  serve  at  once.  If  allowed  to  boil  after  the  chocolate  is 
added  to  the  milk,  it  becomes  oily,  and  loses  flavor. 

Coffee. — Stir  together  2  tablespoonfuls  of  freshly  ground  coffee,  4  of 
cold  water,  and  half  an  egg.  Pour  upon  them  i  pint  of  freshly  boiled 
water,  and  let  them  boil  for  five  minutes.  Stir  down  the  grounds,  and  let  it 
stand  where  it  will  keep  hot,  but  not  boil,  for  five  minutes  longer.  In  serving 
put  sugar  and  cream  in  the  cup  first,  and  pour  the  coffee  upon  them. 

Coffee,  Crust. — ^Take  i  pint  of  crusts — those  of  Indian  bread  are  the 
best — brown  them  well  in  a  quick  oven,  but  do  not  let  them  burn;  pour  over 
them  3  pints  of  boihng  water,  and  steep  for  ten  minutes.  Serve  with  cream. 
This  is  a  nutritious  substitute  for  coffee. 

Coffee  and  Egg. — Boil  together  for  five  minutes  a  tablespoonful  of  ground 


776  APPENDIX 

coffee,  I  egg,  I  pint  of  milk,  and  j  pint  of  boiling  water.  Beat  the  rest  of 
the  egg  and  4  teaspoonfuls  of  sugar  together  until  stiff  and  Hght,  and  strain 
the  boiling  coffee  into  it,  stirring  all  the  time.  Add  2  tablespoonfuls  of  hot 
cream.     This  is  only  to  be  given  in  small  quantities. 

Coffee,  Nutritious. — Dissolve  a  Uttle  gelatin  in  water.  Put  |  ounce  of 
freshly  ground  coffee  into  a  saucepan  with  i  pint  of  new  milk,  which  should 
be  nearly  boiUng  before  the  coffee  is  added;  boil  together  for  three  minutes;  clear 
it  by  pouring  some  of  it  into  a  cup  and  dashing  it  back  again.  Add  the  gelatin, 
and  leave  the  coffee  on  the  back  part  of  the  range  for  a  few  minutes  to  settle. 
If  desired,  beat  up  an  egg  in  a  breakfast-cup,  and  upon  it  pour  the  coffee. 

Coffee,  Rice. — Parch,  and  grind  like  coffee,  half  a  cupful  of  rice.  Pour 
over  it  a  quart  of  boiUng  water,  and  let  it  stand  where  it  will  keep  hot  for  a 
quarter  of  an  hour,  then  strain,  and  add  boiled  milk  and  sugar.  This  is  nice 
for  children. 

Cream  of  Tartar  Lemonade. — To  a  quart  of  boiling  water  add  |  ounce 
of  cream  of  tartar,  the  juice  of  one  lemon,  and  2  tablespoonfuls  of  honey  or 
sugar.    Let  it  stand  on  ice  until  cold.    This  is  a  widely  used  diuretic  beverage. 

Custard,  Soft. — Take  2  tablespoonfuls  of  corn-starch  to  i  quart  of 
milk;  mix  the  starch  with  a  small  quantity  of  the  milk  and  flavor;  beat  up  two 
eggs.  Heat  the  remainder  of  the  milk  to  near  boiling;  then  add  separately 
the  mixed  corn-starch,  the  eggs,  4  tablespoonfuls  of  sugar,  a  Uttle  butter, 
and  salt.     Boil  the  custard  two  minutes,  stirring  briskly. 

Egg  Broth. — Beat  together  i  egg  and  half  a  teaspoonful  of  sugar  until 
very  Ught,  and  pour  on  a  pint  of  boiling  water,  stirring  well  to  keep  it  from 
curdhng.     Add  salt,  and  serve  hot. 

Egg-nog,  No.  1. — Beat  the  white  of  an  egg  stiffly,  then  stir  into  it  in 
turn  a  tablespoonful  of  sugar,  the  yolk  of  the  egg,  a  tablespoonful  each  of  ice- 
water,  milk,  and  wine.     Do  not  beat,  but  stir  very  lightly. 

Egg-nog,  No.  2. — Beat  up  i  egg  with  a  tablespoonful  of  sugar.  Stir 
into  this  a  cup  of  fresh  milk,  i  ounce  of  sherry,  or  J  ounce  of  brandy,  and  add  a 
dash  of  nutmeg. 

Egg-nog,  Hot. — Beat  together  the  yolk  of  an  egg  and  a  tablespoonful 
of  sugar,  and  stir  into  it  a  pint  of  milk  at  the  boiling-point.  Add  a  tablespoon- 
ful of  brandy  or  whisky,  and  grate  a  little  nutmeg  over  the  top. 

Eggs,  Scrambled. — Take  4  eggs,  half  a  teaspoonful  of  salt,  one  pinch 
of  pepper,  one-quarter  cupful  of  milk,  one  tablespoonful  of  butter.  Put  the 
butter  into  a  saucepan;  when  melted  and  hot,  add  the  other  ingredients. 
Stir  over  hot  water  until  of  a  soft,  creamy  consistency.  Serve  on  buttered 
toast. 

Eggs,  Soft-boiled. — Drop  2  eggs  into  enough  boiUng  water  to  cover 
them.  Let  them  stand  on  the  back  of  the  stove  where  the  water  will  keep  hot, 
but  not  boil,  for  eight  minutes.  An  egg  to  be  properly  cooked  should  never 
be  boiled  in  boiling  water,  as  the  white  hardens  unevenly  before  the  yolk  is 
cooked.     The  yolk  and  white  should  be  of  a  jelly-like  consistency. 


SOME    INVALID    AND    CONVALESCENT   FOOD    RECIPES  777 

Gruel,  Cracker.— Pour  i  pint  of  boiling  milk  over  3  tablespoonfuls 
of  fine  cracker-crumbs.  Butter-crackers  are  the  best  to  use.  Add  half  a 
teaspoonful  of  salt,  boil  up  once  all  together,  and  serve  immediately.  Do  not 
sweeten. 

Gruel,  Flour. — Mix  a  tablespoonful  of  flour  with  milk  enough  to  make 
a  smooth  paste,  and  stir  it  into  a  quart  of  boihng  milk.  Boil  for  half  an  hour, 
being  careful  not  to  let  it  burn.  Salt  and  strain.  This  is  good  in  cases  of 
diarrhea. 

Gruel,  Indian-meal. — Mix  a  scant  tablespoonful  of  Indian-meal  with 
a  little  cold  water,  and  stir  into  i  pint  of  boiling  water.  Boil  for  half  an 
hour.  Strain  and  season  with  salt.  Sugar  and  cream  may  be  added,  if 
desired. 

Gruel,  Indian-meal  and  Flour.— Mix  4  tablespoonfuls  of  Indian- 
meal  and  2  tablespoonfuls  of  flour  and  stir  into  a  little  cold  water.  Add 
this  slowly  to  2  quarts  of  boiling  water.  Boil  slowly  three  hours,  adding 
water  from  time  to  time  to  keep  up  the  quantity  to  2  quarts.  Salt  to  taste. 
To  serve,  mix  a  portion  of  this  with  an  equal  quantity  of  milk,  and  warm  to 
taste. 

Gruel,  Oatmeal. — Boil  a  tablespoonful  of  oatmeal  in  a  pint  of  water  for 
three-quarters  of  an  hour,  then  put  it  through  a  strainer.  If  too  thick,  reduce 
with  boiling  water  to  the  desired  consistency. 

Gruel,  Oatmeal,  with  Milk.— Soak  |  pint  of  oatmeal  in  I  quart  of  water 
over  night.  In  the  morning,  add  more  water,  if  necessary,  and  boil  for  an 
hour.  Squeeze  through  a  fine  strainer  as  much  as  you  can,  and  blend  it 
thoroughly  with  a  pint  of  boiling  milk.  Boil  the  mixture  for  five  minutes, 
and  salt  to  taste. 

Irish  Moss. — Wash  thoroughly  a  handful  of  Carrageen  moss,  pour  over 
it  2  cups  of  boiling  water,  and  let  it  stand  where  it  will  keep  hot,  but  not 
boil,  for  two  hours.     Strain,  add  the  juice  of  one  lemon,  and  sugar  to  taste. 

Slippery-elm  may  be  used  in  the  same  way,  a  teaspoonful  of  the  powder 
to  each  cup  of  boiling  water. 

Junket. — Put  I  pint  of  cold  fresh  milk  into  a  clean  saucepan  and  heat 
it  lukewarm  (not  Over  100°  F.) ;  then  add  i  teaspoonful  of  essence  of  pepsin, 
and  stir  just  enough  to  mix;  divide  quickly  into  small  cups  or  glasses  and  let 
stand  until  firmly  jellied,  when  the  junket  is  ready  for  use,  just  as  it  is,  or  with 
sugar;  or  it  may  be  placed  on  ice  and  taken  cold. 

Junket,  Cocoa. — Put  an  even  tablespoonful  of  any  good  cocoa  and  2 
teaspoonfuls  of  sugar  into  a  saucepan;  scald  with  2  tablespoonfuls  of  boiling 
water;  rub  this  paste  smooth;  then  stir  in  thoroughly  ^  pint  of  cold  fresh 
milk;  heat  this  mixture  lukewarm  (not  over  100°  F.) ;  add  i  teaspoonful  of 
essence  of  pepsin,  and  stir  just  enough  to  mix;  divide  quickly  into  small  cups 
or  glasses  and  let  stand  until  firmly  jellied,  when  the  junket  is  ready  for  use; 
or  it  may  be  placed  on  ice  and  taken  cold;  or  it  may  be  served  with  whipped 
cream. 


778  APPENDIX 

Junket,  Egg. — Beat  to  a  froth  one  strictly  fresh  egg;  sweeten  with  2 
teaspoonfuls  of  sugar;  then  stir  in  thoroughly  J  pint  of  cold  fresh  milk;  put 
this  mixture  into  a  clean  saucepan  and  heat  it  lukewarm  (not  over  100°  F.) ; 
stir  in  i  teaspoonful  of  essence  of  pepsin,  and  divide  quickly  into  small  cups 
or  glasses  and  let  stand  until  firmly  jelHed,  when  the  egg-junket  is  ready  for 
use,  just  as  it  is,  or  with  grated  nutmeg;  or  it  may  be  placed  on  ice  and  taken 
cold. 

Lemonade,  Flaxseed. — Into  i  pint  of  hot  water  put  2  tablespoonfuls 
of  sugar  and  3  of  whole  flaxseed.  Steep  for  an  hour,  then  strain,  add  the 
juice  of  a  lemon,  and  set  on  ice  until  required.  This  is  an  efficient  bronchial 
sedative. 

Lemonade  with  Egg. — Beat  i  egg  with  2  tablespoonfuls  of  sugar  until 
very  light,  then  stir  in  3  tablespoonfuls  of  cold  water  and  the  juice  of  a  small 
lemon.     Fill  the  glass  with  pounded  ice,  and  drink  through  a  straw. 

Lime-water. — Pour  2  quarts  of  hot  water  over  fresh  unslaked  lime  of 
the  size  of  a  walnut;  stir  until  slaked,  and  let  it  stand  until  clear,  then  bottle. 
Lime-water  is  often  ordered  with  milk  to  neutrahze  acidity  of  the  stomach. 

Milk  and  Albumen. — Put  into  a  clean  quart  botde  a  pint  of  milk,  the 
whites  of  2  eggs,  and  a  small  pinch  of  salt.  Cork  and  shake  hard  for  five 
minutes. 

Milk-punch. — To  J  pint  of  fresh  cold  milk  add  2  teaspoonfuls  of  sugar 
and  I  ounce  of  brandy  or  sherry.     Stir  until  the  sugar  is  dissolved. 

Milk  and  Water,  Hot. — ^Boiling  water  and  fresh  milk,  in  equal  parts, 
compose  a  drink  commended  in  cases  of  exhaustion,  as  it  is  quickly  absorbed 
into  the  system  with  very  litde  digestive  effort. 

Milk,  Peptonized. — Immediate  Process. — Put  2  tablespoonfuls  (i  oz.) 
of  cold  water  into  a  goblet  or  glass;  dissolve  in  this  one-quarter  of  the  contents 
of  a  peptonizing  tube;  add  8  tablespoonfuls  (4  oz.)  of  warm  milk — not 
boiling;  drink  immediately,  sipping  slowly.  If  J  pint  of  milk  is  required, 
double  the  proportion  of  water,  peptonizing  powder,  and  milk.  Cold  milk 
may  be  used  instead  of  warm,  if  preferred. 

Milk,  Peptonized. — Cold  Process. — Put  a  teacupful  (gill)  of  cold  water 
into  a  clean  quart  bottle  and  dissolve  in  it  by  shaking  thoroughly  the  powder 
contained  in  a  peptonizing  tube;  add  a  pint  of  cold  fresh  milk,  shake  the  bottle 
again,  and  immediately  place  it  on  ice — directly  in  contact  with  the  ice.  Shake 
the  bottle  before  and  after  using.  Peptonized  milk  prepared  by  this  recipe 
is  especially  appreciated  by  patients  who  dislike  the  taste  of  warmed  or  boiled 
milk,  and  ordinarily  it  is  readily  digested  and  assimilated. 

Milk,  Sago. — Wash  a  tablespoonful  of  pearl  sago  and  soak  it  over  night 
in  4  of  cold  water.  Put  it  in  a  double  kettle  with  a  quart  of  milk,  and  boil  until 
the  sago  is  nearly  dissolved.     Sweeten  to  taste,  and  serve  either  hot  or  cold. 

Possett,  Treacle. — Bring  a  cupful  of  milk  to  the  boiling-point  and  stir 
into  it  a  tablespoonful  of  molasses.     Let  it  boil  up  well,  strain  and  serve. 

Raw-meat  Sandwich. — Scrape  the  pulp  from  a  good  steak,  season  to  taste. 


SOME    INVALID   AND   CONVALESCENT   FOOD   RECIPES  779 

and  spread  on  thin  slices  of  bread.  Sear  the  bread  slightly  and  serve  as  a 
sandwich. 

Soup,  Rice. — Take  J  pint  of  chicken  stock  and  2  tablespoonfuls  of  rice. 
Let  them  simmer  together  for  two  hours,  then  strain  and  add  half  a  pint  of 
boiling  cream  and  salt  to  taste.     Boil  up  once  and  serve  hot. 

Soup,  White  Celery. — To  ^  pint  of  strong  beef-tea  add  an  equal  quantity 
of  boiled  milk,  slightly  and  evenly  thickened  with  flour.  Flavor  with  celery 
seed  or  pieces  of  celery,  which  are  to  be  strained  out  before  serving.  Salt 
to  taste. 

Sweetbreads. — Keep  the  sweetbreads  in  cold  water  until  ready  to  use; 
then  remove  the  fat,  ducts,  and  membranes.  Put  them  into  boiling  salted 
water,  add  one  tablespoonful  of  lemon-juice,  and  cook  twenty  minutes.  Drain 
and  cover  with  cold  water.  Let  them  stand  a  few  minutes,  then  drain,  and 
they  are  ready  for  the  tray. 

Tamarind-water. — A  very  refreshing  drink  may  be  made  by  adding  i 
pint  of  hot  water  to  i  tablespoonful  of  preserved  tamarinds,  and  setting 
aside  to  cool. 

Tea. — Tea  should  be  made  in  an  earthen  pot,  first  rinsed  ^^ith  boiling 
water.  Allow  a  teaspoonful  of  tea  to  each  haK  pint  of  water.  Put  in  the  tea, 
and  after  letting  it  stand  for  a  few  minutes  in  the  steaming  pot,  add  the  water 
freshly  boiling,  and  let  it  stand  where  it  will  keep  hot,  but  not  boil,  for  from 
three  to  five  minutes. 

Tea,  Corn. — Parch  brown  a  cupful  of  dry  sweet  com,  grind  or  pound  it  in 
a  mortar.  Pour  over  it  two  cups  of  boiling  water,  and  steep  for  a  quarter  of  an 
hour. 

Toast,  Milk. — Take  i  cupful  of  milk,  half  a  tablespoonful  of  corn-starch, 
half  a  tablespoonful  of  butter,  2  sUces  of  drv-  bread,  i  saltspoonful  of  salt. 
Scald  the  milk.  Melt  the  butter  in  a  saucepan ;  when  hot  and  bubbling  add  the 
corn-starch.  Pour  in  the  hot  milk  slowly,  beating  all  the  time  until  smooth. 
Let  it  boil  up  once.  Then  add  the  salt.  Toast  the  slices  of  bread.  Pour 
the  thickened  milk  over  the  slices.     Let  it  stand  five  minutes;  serve. 

Toast,  Peptonized  Milk. — Over  2  slices  of  toast  pour  i  gill  of  pep- 
tonized milk  (cold  process) ;  let  stand  on  the  back  part  of  the  range  for 
thirty  minutes.  Serve  warm  or  strain  and  serve  fluid  portion  alone.  Plain 
light  sponge-cake  may  be  similarly  digested. 

Toast-water. — Toast  3  rather  thin  slices  of  stale  bread  to  a  very  dark 
brown,  but  do  not  bum.  Put  into  a  pitcher  and  pour  over  them  a  quart 
of  boiUng  water.  Cover  closely,  and  let  it  stand  on  ice  until  cold.  Strain. 
A  httle  v.ine  and  sugar  may  be  added  if  desired.     Good  in  diarrhea. 

Wine,  Mulled. — Into  half  a  cup  of  boiling  water  put  2  teaspoonfuls 
of  broken  stick  cinnamon  and  a  half  dozen  whole  cloves.  Let  them  steep  for 
ten  minutes  and  then  strain.  Beat  together  until  very  light  2  eggs  and  2 
tablespoonfuls  of  sugar,  and  stir  into  the  spiced  water.  Pour  into  this,  from 
a  height,  a  cupful  of  sweet  wine,  boiling  hot.     Pouring  it  several  times  from 


780  APPENDIX 

one  pitcher  to  another  will  make  it  light  and  foamy.     Serve  hot.     The  wine 
should  not  be  boiled  in  tin. 

Wine  Whey. — Heat  ^  pint  of  milk  to  the  boiling-point,  and  pour  into 
it  a  wineglass  of  sherry.  Stir  once  round  the  edge,  and  as  soon  as  the 
curd  separates,  remove  from  the  fire  and  strain.  Sweeten  if  desired.  The  whey 
can  be  similarly  separated  by  lemon-juice,  vinegar,  or  rennet.  With  rennet 
whey,  use  salt  instead  of  sugar. 


INDEX  OF  AUTHORS 


Abel,  301 
Abram,  172 
AJlaben,  J.  E.,  25 
Allen,  R.  W.,  724,  731 
Allport,  W.  H.,  499 
Anderson,  543 
Arnaud,  G.,  444 
Aspell,  259 

Baillet,  436 

Bainbridge,  174 

Baker,  W.  A.,  480 

Balch,  F.  G.,  563 

Baldwin,  H.,  173 

Baldwin,  J.  F.,  25 

Baldy,  J.  M.,  27,  493 

Ballance,  567,  568 

Barber,  M.  A.,  765 

Barker,  293 

Bartlett,  103 

Barton,  195 

Bassini,  E.,  442 

Baum,  268 

Baumgarten,  126 

Beck,  E.,  370 

Beck,  E.  G.,  241 

Becker,  E.,  95,  172 

Beebe,  S.  P.,  395 

Berger,  P.,  442 

Bernheim,  72,  76 

Bernlieim,  B.  M.,  239 

Berthoumeau,  145 

Bevan,  A.  D.,  173,  174,  175,  341,  430 

Bichat,  X.,  196 

Bid  well,  104 

Bier,  A.,  230,  233,  560 

Bilergeil,  299 

Bischoff,  71 

Bisb)p,  553 

Blake,  J.  A.,  419 

Blake,  J.  B.,  31,  97,  168,  299 

Bland-Sutton,  99 

Blanlaret,  34 


Blasius,  71 

Blumj&eld,  33 

Blundell,  71 

Boas,  126 

Boise,  E.,  82 

Bolton,  C.,  412 

Boos,  W.  F.,  146 

Boyd,  126 

Brackett,  E.  G.,  173,  175,  176,  569 

Bradford,  E.  H.,  239 

Brewer,  W.  H.,  173 

Brieger,  612 

Briggs,  F.  M.,  397 

Briggs,  W.  T.,  545 

Briscoe,  J.  C.,  724 

Broca,  268 

Brockway,  573 

Broughton,  728 

Brown,  F.  T.,  540 

Brown-Sequard,  328 

Brun,  v.,  176 

Brunton,  Sir  L.,  116 

Bryant,  J.  D.,  560 

Buck,  560 

Bull,  W.  T.,  442      . 

Bulloch,  614,  615,  637 

Bulloch,  W.,  750 

Bumm,  264 

Bumm,  E.,  493 

Burrell,  H.  L.,  560,  589 

Busch,  105 

Busch,  M.,  299 

Buxton,  169 

Buxton,  H.  T.,  25 

Byford,  300 

Cabot,  A.  T.,  480,  544 
Cackovic,  M.  von,  92,  259 
Calmette,  A.,  732 
Calnt,  572 
CampVjell,  R.,  173 
Cannon,  W.  B.,  411 
Cargile,  C,  299 

781 


782 


INDEX   OF   AUTHORS 


Carlson,  617 

Carrel,  72,  562 

Carriere,  268 

Castellani,  A.,  765 

Catz,  107 

Cavallo,  335 

Champneys,  381 

Chapman,  169 

Chavasse,  559 

Cheever,  D.  W.,  271,  276,  590 

Chevasser,  M.,  398 

Clark,  J.  G.,  502 

Codman,  E.  A.,  239 

Coffey,  R.  C,  25,  220 

Cole,  R.  I.,  703 

Coley,  W.  B.,  341,  442,  771 

Connell,  427 

Connor,  158 

Conti,  172 

Cooper,  560 

Corner,  167 

Cotton,  F.  J.,  572,  586 

Couvelaine,  176 

Couvelaire,  A.,  506 

Craig,  A.  B.,  299 

Craig,  D.  C,  153 

Craig,  D.  H.,  279,  299 

Crandon,  L.  R.  G.,  148,  454,  569 

Crile,  G.  W.,  72,  73,  77,  82,  85,  86,  88,  112 

Croom,  J.  H.,  38 

Crouch,  167 

Crouse,  H.,  502,  579 

Cullen,  T.  S.,  502 

Cunningham,  J.  H.,  Jr.,  201,  204,  205,  206, 

439>  440,  441,  757 
Curtis,  F.,  417 

Gushing,  Hayward  W.,  442,  590 
Cutler,  C.  N.,  80 

Da  Costa,  617,  620,  686 

Daguin,  145 

d'Arsonval,  342 

Davis,  E.  P.,  506 

Davis,  J.  S.,  285 

Dawson,  J.  B.,  452,  453 

De  Forrest,  246 

De  Garmo,  292 

De  Haen,  335 

de  Normandie,  R.  L.,  403,  506 

De  Vilbiss,  359 

Dent,  278 

Denys,  605,  606 

Denys,  Jean,  71 


Desault,  196 
Dewey,  C.  G.,  276,  278 
Dickinson,  W.  H.,  183 
Doderlein,  A.,  493 
Dorsett,  259 
Douglas,  605 
Doyen,  E.,  483 
Duchenne,  336 
Dudley,  E.  C,  484 
Dupuytren,  276 
Duschinsky,  299 
Dyball,  264 

Edgar,  J.  C.,  509 

Edsall,  175 

Edwards,  S.,  452 

Ehrenfried,  A.,  80,  126,  572,  593,  594,  595 

Ehrlich,  612 

Ehrlich,  P.,  415,  603,  628 

Eiselsberg,  A.  von,  38 

Eisendrath,  D.  N.,  43,  83 

Elifagaray,  268 

Elliot,  J.  W.,  435 

Ellis,  A.  G.,  299,  300 

Elsberg,  72,  75,  77 

Emmet,  T.  A.,  475,  476,  484 

Englehardt,  278 

Estlander,  409 

Estradere,  328 

Evans,  H.  M.,  390 

Ewald,  125 

Falconer,  J.  L.,  173 

Faraday,  336 

Faure,  567 

Favill,  173,  174,  175 

Fenwick,  H.,  752  ' 

Fenwick,  W.  S.,  263 

Finney,  J.  M.  T.,  156,  416 

Finsen,  336 

Fisher,  82 

Fleming,  614,  680,  681 

Fleming,  A,  719 

Floyd,  C,  724,  748 

Forge,  273 

Fothergill,  J.  M.,  326 

Fowler,  G.  R.,  24,  467 

Fowler,  R.  H.,  24 

Fraenkel,  A.,  100,  102 

Frangenheim,  A.,  239 

Franklin,  Benj.,  335 

Fraser,  146 

Freeman,  623 


INDEX   OF   AUTHORS 


783 


Friedenwald,  126 
Friedman,  L.  V.,  489,  506 
Fulton,  F.  T.,  263 
Furstner,  276 

Galvani,  336 
Gangani,  268 
Gatch,  W.  D.,  25 
Gerster,  106,  589 
Gersuny,  556 
Gibbon,  48 
Gibson,  C.  L.,  102 
Gibson,  C.  P.,  428 
Gibson,  E.  L.,  156 
Gigli,  L.,  493 
Gilchrist,  T.  C,  719 
GUliam,  D.  T.,  25,  468,  493 
Gocht,  560 

Goldstein,  M.  A.,  377 
Goldthwait,  J.  E.,  575 
Goodman,  E.  H.,  174 
Gottheil,  258 
Graham,  A.,  36 
Graham,  Douglas,  316 
Green,  C.  M.,  506,  509 
Green,  R.  M.,  697 
Greig-Smith,  215 
Grevan,  172 
Groeningen,  82 
Griineisen,  465 
Gunn,  259 
Guthrie,  72,  93,  562 
Guthrie,  L.,  174,  178 

Haddaeus,  259 

Haffkine,  W.  M.,  696,  765 

Hahn,  E.,  427 

Hall,  R.,  96 

Hallowell,  562 

Halstead,  A.  E.,  165 

Halsted,'W.  S.,  390,  442 

Hamilton,  592 

Hammond,  P.,  400 

Harrington,  C,  354 

Harris,  B.,  728 

Harris,  M.  L.,  299 

Harris,  R.  P.,  492 

Hartman,  372 

Hartwell,  H.  F.,  697,  702,  703,  746 

Harvey,  W.  W.,  407 

Harvey,  William,  71 

Harvie,  415 

Hawes,  J.  B.,  748 


Hawkes,  F.,  156,  219 
Hay,  146 
Hayem,  267 
Hecker,  175 
Heile,  154 
Heineck,  A.  P.,  489 
Heinemann,  116 
Hektoen,  617,  650 
Henle,  167 
Hepburn,  T.  N.,  77 
Herczel,  547 
Herzog,  276 
Hewitt,  167 
Hilton,  226 
Hirsch,  M.,  170 
Hofmeier,  99 
Hofmeier,  N.,  502 
Holding,  341 
Hood,  W.  P.,  329 
Horsley,  393 
Howard,  W.,  366 
Howe,  W.  C,  561 
Howell,  W.  H.,  82 
Howland,  174 
■  Hubbard,  J.  C,  173,  451,  563 
Humphry,  R.  E.,  266 
Hunner,  G.  L.,  546 
Hunter,  W.,  178 
Hurd,  278 
Hutchins,  W.  H.,  261,  262 

Inman,  a.  C,  736,  764 

Irons,  659 

Irons,  E.  E.,  703,  704 

Jackson,  D.  D.,  87 

Jackson,  H.  B.,  422 

Jacobson,  N.,  262 

Jacobson,  W.  H.  A.,   359,  367,  376,   380, 

381,  394,  416,  422,  449,  547 
Jaeger,  507 
Jeanbrau,  273 
Johnson,  341 
Johnson,  A.  B.,  464 
Jones,  C,  745,  751,  753,  757,  760 
Jones,  D.  F.,  264 
Jorgenscn,  612 

Keen,  W.  W.,  82 

Keetley,  451,  453 

Keith,  A.,  112 

Kelly,  H.  A.,  169,  476,  493,  497,  502 


784 


INDEX   OF   AUTHORS 


Kelly,  J.  A,  172 
Kemp,  45 
Kendirdjy,  107 
Kennan,  160 
Kennedy,  567 
Kent,  298 
Klapp,  239 
Kleinertz,  R.,  259 
Knapp,  L.,  176 
Kccher,  571 
KoUe,  W.,  765 
Kraske,  553 
Kredel,  256 
Kronecker,  116 
Kuhn,  F.,  112 
Kulka,  263 
Kummer,  301 

Laborde,  112 

Ladd,  W.  E.,  173 

Laffer,  158,  160 

Lamb,  618 

Lambert,  562 

Lambert,  A.,  271 

Landois,  71 

Lane,  W.  A.,  367 

Lauenstein,  C,  299 

Leary,  T.  J.,  268,  768 

Leathes,  174 

Le  Clef,  605 

Le  Normant,  102 

Lecene,  10 1 

Lee,  W.  E.,  38 

Legal,  177 

Lejars,  466 

Leland,  G.  A.,  Jr.,  409 

Leopold,  C.  G.,  493 

Leube,  122,  125 

Levy,  169 

Lewis,  B.,  547 

Leydon,  82 

Lincoln,  616 

Lindemann,  167* 

Littauer,  212 

Locke,  113 

Loeb,  L.,  773 

Lommel,  268 

Lessen,  276 

Lothrop,  H.  A.,  442 

Lovett,  R.  W.,  598 

Low,  H.,  173,  175,  176 

Lower,  71 

Lund,  F.  B.,  19S,  199,  245,  300,  499,  562 


Lusk,  W.  C,  557 
Lyon,  82 

Macewen,  592 

Madsen,  612 

Mansell-Moullin,  C.  W„  38 

Marcy,  H.  O.,  444 

Marpan,  175 

Martin,  A.,  299 

Martin,  W.,  419 

Marvel,  E.,  298 

Mason,  A.  L.,  107 

Mason,  N.  R.,  506 

Matas,  R.,  260,  563 

Mauclaire,  102 

Maunsell,  453 

Mayo,  C.  H.,  163,  391,  564 

Mayo,  W.  J.,  411,  442,  597 

Mayo-Robson,  A.  W.,  38 

McArthur,  A.  N.,  173 

McArthur,  L.  L.,  442 

McBurney,  435,  454 

McCardie,  W.  J.,  266 

McCoUom,  J.  H.,  130 

McCormack,  Sir  W.,  586 

McDonald,  E.,  475 

McGuire,  S.,  25 

McKay,  38,  96 

McKay,  W.  J.  S.,  286 

Meakins,  J.  C.,  703 

Meisse,  T.,  90 

Meltzer,  262 

Meltzer,  S.  J.,  82 

Metchnikoff,  115,  116 

Metchnikoff,  E.,  605,  628 

Meyer,  E,  W.,  586 

Meyer,  W.,  230,  468 

Mikulicz,  221,  448 

Mintz,  568 

Mitchell,  S.  Weir,  82 

Mixter,  S.  J.,  421 

Mocquot,  93 

Moennighoff,  153 

Momberg,  87 

Monks,  G.  H.,  468 

Monprofit,  A.,  415 

Moore,  F.  C,  126 

Moorehouse,  C.  W.,  82 

Morris,  R.  T.,  352 

Morrow,  P.  A.,  258 

Mosetig-]Moorhof,  592 

Moynihan,  B.  G.  A.,  434,  435,  442 

Miiller,  169,  172,  298 


INDEX    OF   AUTHORS 


785 


Mummery,  P.  L.,  83,  167 

Munro,  J.  C,  106,  168,  464,  465,  466 

Murphy,  F.  T.,  563 

Murphy,  J.  B.,  44,  105,  427,  499 

Murray,  F.  W.,  5S4 

Musser,  J.  H.,  465 

Nauwerck,  167 

Neuber,  592 

Neugebauer,  F.,  286,  287,  288 

Newell,  F.  S.,  199,  503,  506,  509 

Newman,  S.  E.,  44 

Nichols,  E.  H.,  590,  592 

Nichols,  J.  B.,  178 

Nicolaysen,  586 

Noble,  292 

Noble,  C.  P.,  475 

Noon,  L.,  695 

Nuttall,  606 

OCHSNER,  33,  241,  349,  369,  408,  410,  414 

O'Dwyer,  384 
O'Leary,  C,  181 
Olshausen,  259 
Olshausen,  R.,  483,  493 
Oilier,  590 
Opie,  620 

Osgood,  G.,  80,  173 
Osgood,  R.  B.,  575 

Packard,  H.,  531 
Paget,  263 
Painter,  C.  F.,  575 
Pare,  A.  276 
Park,  R.,  258,  266 
Parkhill,  585 
Parsons,  245 

Paterson,  H.  J.,  412,  413 
Patterson,  766 
Patterson,  M.  S.,  764 
Paul,  F.  T.,  393,  421 
Paynes,  212 
Payr,  72 
Pean,  J.,  483 
Peckham,  568 
Penrose,  169 
Petersen,  560 
Peterson,  R.,  259 
Petters,  172 
Pfahler,  341 
Pfannensteil,  292 
Pfeiflfer,  609 
Pike,  93 

50 


Pilcher,  J.  D.,  228 
Pilcher,  L.  S.,  543 
Pinard,  A.,  489 
Pliny,  iSo 
Polak,  158,  159 
Porter,  C.  A.,  262 
Post,  A.,  263 
Pozzi,  S.,  484 
Pratt,  J.  H.,  263 
Prescott,  W.  H.,  168,  169 
Provandie,  P.,  81 
Pryor,  W.  R.,  4S0,  483 

queirolo,  72 

Ranzi,  102 

Raw,  N.,  749 

Reed,  C.  B.,  493 

Reicher,  K.,  175 

Remak,  336 

Reynolds,  E.,  199,  506 

Ricard,  589 

Rice,  A.  G.,  173 

Richards,  174 

Richardson,  M.  H.,  430,  449 

Richardson,  O.,  262 

Richardson,  W.  G.,  259 

Rickard,  433 

Riegel,  122,  126 

Ringer,  113 

Ritter,  C.,  37 

Rives,  264 

Robb,  H.,  87  . 

Roberts,  W.  H.,  266 

Robinson,  S.,  409 

Robson,  A.  W.  M.,  416 

Rodman,  341 

Rogers,  J.,  262,  395 

Rogers,  L.,  436 

Rohe,  276,  278 

RoUins,  W.,  347 

Rose,  E.,  259 

Rosenow,  E.  C,  619,  642,  698 

Royster,  218 

Rugh   267 

Ruhrah,  126 

Russell,  435 

Sabouratjd,  R.,  719 
Sampson,  J.  A.,  502 
Sanborn,  G.  P.,  601 
Sanger,  567 
Sargent,  245 


786 


INDEX   OF   AUTHORS 


Sartoli,  99 
Saxon,  43 

Scannell,  D.  D.,  454,  S^S 
Schachner,  286 
Schamberg,  J.  F.,  728 
Schede,  409,  592 
Schlatter,  415 
Schmieden,  230 
Scholten,  176 
Schopf,  442 
Schrack,  K.,  175 
Sears,  G.  G.,  278 
Senn,  N.,  587 
Sequeira,  J.  Jl.,  750 
Sertoli,  A.,  468 
Sever,  J.  W.,  173 
Shephard,  433 
Shepherd,  F.  J.,  258 
Sherman,  562 

Sichel,  276 

Sick,  567 

Sievert,  105 

Sigault,  J.  R.,  492 

Silk,  163 

Simpson,  F.  F.,  493 

Sims,  J.  M.,  476 

Sippel,  178 

Skene,  A.  J.  C,  495 

Smith,  Greig,  169 

Smith,  Harmon,  370 

Smith,  Theobald,  764 

Soper,  121,  149,  150 

Soubeyran,  264 

Spencer,  437 

Spitzka,  E.  A.,  112 

Stellig,  82 

Stern,  298 

Steward,  359,  367,  380,  394,  422 

Steward,  F.  J.,  547 

Stone,  A.  K.,  92 

Stone,  I.  S.,  258 

Stone,  J.  S.,  173,  175,  176 

Stowe,  H.  M.,  489 

Strauss,  83 

Streeter,  E.  C.,  697,  746 

Strong,  A.  L.,  765 

Stuart,  93 

Sylvester,  109 

Syme,  307 

Symes,  W.  L.,  S3,  181 

Telford,  173 
Thienhaus,  435 


Thiriar,  263 

Thompson,  103,  126,  176,  642 
Thompson,  R.  A.,  106 
Thompson,  W.  G.,  697 
Thorndike,  P.,  140,  263 
Torbert,  J.  R.,  159,  506 
Tracy,  M.,  771 
Tracy,  S.  E.,  497,  502 
Trendelenburg,  104,  105,  592 
Treves,  Sir  F.,  157,  363,  437 
Trudeau,  763 
Trudeau,  E.  L.,  748 
Tubby,  A.  H.,  572 
Tunncliffe,  R.,  766 

Unna,  719 
Unterberger,  246 
Urwick,  614 

Van  der  Bogart,  256 
Van  Kaathoven,  165 
Velpeau,  196 
Vogel,  298,  299 
von  Courty,  276 
von  Graff,  246 
von  Lichtenberg,  169 

Walker,  J.  W.  T.,  752,  753,  754,  75^ 

Wallace,  C.  H.,  163 

Walthard,  279 

Wandel,  261 

Warren,  J.  C.,  45° 

Wassermann,  A.,  695 

Waterman,  N.,  87 

Watkins,  T.  J.,  475 

Watson,  F.  S.,  512,  534,  536,  544 

Weaver,  G.  H.,  72S,  766 

Webb,  G.  B.,  763 

Webster,  J.  C,  300,  493 

Wechsler,  B.  B.,  44 

Weil,  267 

Weir,  451,  556 

Weir,  R.,  597 

WeUs,  H.  G.,  175 

Wertheim,  E.,  502 

Wesley,  John,  335 

Western,  750 

Western,  G.  T,,  74S,  749 

White,  93 

Whitfield,  A.,  719 

Willem,  556 

Williams,  E.  U.,  724 

WiUiams,  F.  H.,  341,  346,  347 


INDEX   OF   AUTHORS 


787 


Williams,  J.  B.,  176 
Williams,  J.  T.,  506 
Williams,  J,  W.,  503,  509 
Williams,  W.  W.,  763 
Wilson,  286 
Wilson,  H.  A.,  587 
Witherspoon,  T.  C,  163 
Wood,  546 

Wright,  A.  E.,  115,  605,  612,  615,  616,  618, 
620,  628,  642,  648,  696,  738 


Wright,  Sir  A.  E.,  229 
Wynn,  W.  H.,  728 

Young,  E.  B.,  480,  499 

Zabludowski,  326 
Zacharius,  259 
Zander,  589 
Zweifel,  P.,  492 


INDEX 


A.  S.  B.  PILL,  145 

Abdomen,  massage,  for  defecation,  144 

operations  on,  411 
Abdominal  adhesions,  x-ray  treatment,  340 

dressing,  layout,  209 

hysterectomy,  499 

swathes,  301 

wound,  bursting  of,  162 
strapping,  201 
Abortion,  484 
Abscess,  alveolar,  369 

cerebral,  400 

ischiorectal,  549 

of  breast,  403 

of  Gartner's  canal,  507 

of  groin,  570 

of  liver,  428 

of  neck,  397 

pelvic,  478 

peritonsillar,  377 

prostatic,  532 

psoas,  569 

retropharyngeal,  377 

subdiaphragmatic,  107 

subphrenic,  107 

vulvovaginal,  477 
Acetone  in  children,  175 

in  pregnancy,  176 

means  death  of  fetus,  176 

source  of,  174 

test  for^  177 
Acetonemia,  172 

jaundice  in,  177 

symptoms,  177 

treatment,  178 
Acetonuria,  statistics,  173 
Acne,  vaccine  treatment  of,  718 
Actinomycosis  of  pleura,  408 
Active  immunity,  603 
Acute  gastric  dilatation,  projjhylaxis  of,  160 

treatment,  161 
Adenocystoma  of  ovary,  494 
Adenoids,  373 


Adhesions,  294 

and  olive  oil,  299 

causes,  295 

exercises  for,  300 

materials  to  prevent,  299 

nasal,  371 

non-operative  treatment,  300 

prophylaxis,  297 

symptoms,  296 
Adrenalin,  danger  of,  87 

infusion,  87 
Aerogenes  capsulatus,  262 
Agglutination  test,  682 
technique  of,  684 
Agglutinins,  604 
Alcohol  and  operation,  271 

as  a  habit,  270 
Alcoholism,  270 
Alexander's  operation,  506 
Alveolar  abscess,  369 
Amputation  of  ankle,  307 

of  arm,  311,  559 

of  both  bones,  308 

of  fingers,  559 

of  forearm,  559 

of  hip,  310,  559 

of  knee,  309 

of  leg,  560 

of  shoulder,  559 

of  shoulder-girdle,  559 

of  tarsus,  307 

of  thigh,  560 

of  toes,  560 
Amputations  in  general,  558 
Anastomosis  of  nerve,  567 
Anesthesia,  27 

danger  of  repeated,  171 

first  dressing  under,  218 

morphin  after,  35 
atropin  before,  35 

nephritis  after,  169 

paralysis  after,  165 

pneumonia  after,  166 


789 


79° 


INDEX 


Anesthesia,  relation  of  alcohol  to,  271 

sequelae  of,  164 
Anesthetic,  after  the,  28 

conjuncti\atis,  165 

in  head  cases,  359 

recovery  from,  29 

restraint  after,  29 
Anesthetist,  27 

nurse  as,  27 
Anesthol,  27 
Aneurysm,  563 
Ankle,  strapping,  201 
Ankylosis,  electric  treatment,  339 
Anteflexion,  489 
Anterior  mre-sphnt,  582 
Antiseptic  varnish,  363 
Antiseptics,  futility  of,  602 
Antitetanic  preparation,  261 

serum,  261 
Antitoxic  serum,  604 
Antitropins,  604 
Antit}^hoid  inoculation,  609 
Antrum  disease,  vaccine  treatment  of,  725 

of  Highmore,  372 
Anuria,  539 
Anus,  artificial,  248 

fissure  of,  548 

fistula  of,  548 

imperforate,  549 

operations  on,  549 
Aperient  waters,  145 
Appendicitis,  454 
Appendicostom}',  451 
Apple -water,  774 
Arc  light  therapy,  344 
Arrowroot,  774 
Arterial  suture,  562 

Arteriosclerosis,  autocondensation  for,  340 
Arteriovenous  anastomosis,  563 
Arthritis,  gonorrheal,  vaccine  treatment  of, 
702 

purulent,  590 

suppurative,  vaccine  treatment  of,  707 

vaccine  treatment  of,  700 
Artificial  anus,  248 

hand,  311 

Hmbs,  307 

respiration,  109 
prone  method,  in 
supine  method,  109 
Asafetida  for  flatus,  152 
Aseptic  wounds,  dressing,  210 
Asphyxia,  109 


Atresia  of  uterus,  506 

of  vagina,  506 
Atrophy  of  muscle,  treatment  of,  338 
Atropin  for  paresis  of  bowels,  153 
Autocondensation,  technique,  342 
Autoinoculation,  623 

dangers  of,  638 

in  consumption,  624 

in  gonorrheal  arthritis,  624 

in  tuberculous  bones,  625 
salpingitis,  625 
spine,  626 

induced,  624 


Bacillus  coli,  768,  770 

Friedlander,  768 

fusiformis,  351 

pyocyaneus,  227 
dosage,  768 

typhosus,  dosage,  768,  770 
Bacteria,  kilhng  of,  for  vaccines,  763 
Bacterial  emulsion,  675 

vaccine.     See  Vaccine. 
definition  of,  610 
Bactericidins,  604 
Bacteriolysins,  604 
Bandage,  Barton,  195 

Boston  Lying-in  Hospital,  199 

Desault,  196 

figure-of-8,  188 

for  varicose  veins,  191 

many-tailed,  200 

modified  Barton,  195 

of  heel,  190 

of  hip,  189 

of  shoulder,  190 

perineal  dressing,  206,  207,  208 

plaster-of-Paris,  191 
improper  method,  193 

recurrent,  195 
of  head,  195 

rolling  the,  187 

to  start  a,  187 

to  remove  a,  187 

spica,  189 

spiral  reverse,  189 

stump,  195 

suspensory,  203 

T-,  200 

Velpeau,  197 
Bandages,  commercial  roller,  186 
Bandaging,  186 


INDEX 


791 


Barley-water,  774 
Bartholin's  gland,  cyst  of,  478 
Barton  bandage,  195 
Bassini  operation,  442 
Baths  before  operation,  350 
Beard,  preparation  of,  355 
Beck's  paste,  241 
Bed  blocks,  18 

making  of,  19 
Bed-board,  iS 
Beds,  specifications  of,  17 
Bedside  chart,  22 
Bed-sores,  282 

causes,  282 

prevention,  283 

treatment,  285 
Beebe's  serum,  395 
Beef-essence,  774 
Beef-juice,  775 
Beef -tea,  peptonized,  775 

with  oatmeal,  775 
Bellocq's  cannula,  372 
Bevan's  incision,  430 
Bier  apparatus,  235 

h}'peremic  treatment,  230 
for  head,  234 
for  neck,  234 
for  testicles,  235 
in  immunization,  629 
Bladder,  exstrophy  of,  546 

operations  on,  543 

preparation  of,  357 

septic  infection  of,  141 
Blue  screen,  therapy,  344 
Bone,  tuberculosis  of,  vaccine  treatment  of, 

748 
Bone-peg  in  fractures,  585 
Bone-setting,  so-called,  329 
Bone-wax,  592 

Boston  L}ing-in  Hospital  bandage,  199,  402 
Bowels,  care  of,  143 
Bow-legs,  592 

Brachial  plexus,  suture  of,  567 
Brain  operations,  358 
Branchial  cleft  sinus,  398 

cyst,  398 
Breast,  abscess  of,  403 

amputation  of,  401 

bandage,  199,  402 

tumors  of,  402 
Breeze,  electric,  342 
Briggs'  cannula  for  abscess,  397 
Bronchitis  after  anesthesia,  167 


Bronchopneumonia  after  anesthesia,  167 
Broth,  chicken,  775 

clam,  775 

mutton,  775 

oyster,  775 
Bubo,  inguinal,  570 
Buck's  extension,  582 
Bunion,  597 
Burns  from  hot-water  bag,  165 

of  face  from  anesthetic,  165 
Bursting  of  abdominal  wound,  162 

Cabot  wire-splint,  579 

Calomel,  146 

Cancer  of  rectum,  553 

radium  treatment,  347 

^-ray  treatment,  341 
technique,  346 
Cannula  (Briggs)  for  abscess,  397 
Carbolic  acid  poisoning,  257 
Carbuncle  of  neck,  397 

vaccine  treatment  of,  721 

vaccine  treatment  of,  719 
Cargile  membrane,  299,  372 
Carminatives,  151 
Cartilage  of  knee,  588 
Caruncle,  excision  of  urethral,  477 
Cascara,  145 
Castor  oil,  145 
Castration,  518 

Casts,  shower  of,  after  anesthesia,  170 
Cataplasma  kaoUni,  228 
Catharsis  before  operation,  349 

by  foods,  144 

by  massage,  144 
Cathartics,  145 
Catheter,  134,  135 

fever,  140 

internal  antisepsis  in,  142 

lubrication  of,  136 

method  of  retaining,  521 

sterilization  of,  135 
Catheterization,  132 

in  female,  134 

in  male,  134 
Cerebral  abscess,  400 
Cer\-ix  operation,  preparation  for,  356 

uteri  operation,  483 
Cesarean  section,  503 
Charcoal  poultice,  228 
Chart,  bedside,  22 

clinical,  22 

nurse's,  21 


792 


INDEX 


Chest,  gunshot  wounds,  409 

stab  wounds,  409 

soreness  after  anesthesia,  164 
Chicken  broth,  755 
Chloralamid  for  alcoholism,  275 
Chloretone  for  tetanus,  262 
Chloroform,  27,  34 

action  on  liver,  174 

as  respiratory  irritant,  167 

poisoning,  delayed,  175 

vomiting,  34 
Chocolate,  775 

Cholecystectomy,  indications  for,  430 
Cholecystenterostomy,  433 
Cholecystgastrostomy,  434 
Cholecystotomy,  431 
Choledochectomy,  435 
Choledochenterostomy,  435 
Choledochoduodenostomy,  435 
Choledochostomy,  435 
Choledochotomy,  434 
Chopart's  amputation,  307 
Chronic  infections,  reasons  for,  621 
Cigarette  drain,  219,  220 
Circumcision,  514 
Citrate  and  saline,  229,  632,  690 
Clam  broth,  775 

Clamp  and  cautery  operation,  550 
Cleaning  before  bandaging,  187 
Cleansing  enema,  122 
Cleft,  branchial,  398 
Cleft-palate,  365 

speech  after,  366 
Clinical  chart,  22 
Club-foot,  593 
Cocain  habit,  272 
Coffee,  775 

and  egg,  775 

crust,  775 

habit,  272 

nutritious,  776 

rice,  776 
Coley  treatment  for  sarcoma,  771 

results  of,  772 
Collapse,  97 

Collodion  after  hernia  operation,  439 
Colon  vaccine,  preparation  of,  673 
Colostomy,  421 

Colpotomy  for  pelvic  abscess,  478 
Coma,  diabetic,  94 

uremic,  95 
Compound  fractures,  576 
Conjuncti\'itis  after  anesthesia,  165 


Convalescence,  general  treatment,  280 

Convalescent  recipes,  774 

Corpuscular  mixture,  675 

Coxa  vara,  592 

Cream  of  tartar  lemonade,  776 

water,  511 
Crepe  Hsse  for  dressings,  211 
Cribbing,  151 
Crile  cannula,  73 
Crochet  hook  for  stitch  sinus,  243 
Croton  oil,  147 

Cunningham  hernia  spica,  439,  440,  441 
Curettage  of  uterus,  484 
Custard,  soft,  776 
Cutaneous  rashes,  253 
Cyst,  branchial,  398 

hydatid,  of  liver,  429 

of  Bartholin's  gland,  478 
Cystitis,  136 

causes  of,  136 

local  treatment,  138 

operative  treatment,  139 

prophylaxis  of,  137 

symptoms,  136 

treatment,  137,  138,  139 

vaccine  treatment,  138 
Cystocele,  474 
Cystocolostomy,  547 
Cystostomy,  vaginal,  545 
Cystotomy,  lateral,  545 

suprapubic,  543 
Cysts,  ovarian,  493 

Death,  sudden,  97 

Decubitus,  282 

Defecation,  importance  of  habit,  143 

mechanism  of,  143 
Delirium  tremens,  119 
causes  of,  273 
symptoms  of,  273 
treatment  of,  274 
D epilation  versus  shaving,  352 
Depilatory  paste,  352 
Desault  bandage,  196 
Diabetes,  chloroform  in,  94 
diet  before  operation,  178 
Diabetic  coma,  94 
Diacetic  acid,  test  for,  177 
Diagnosis  of  tuberculosis  by  autoinocula- 
tion,  735 
by  opsonic  index,  735 
Diet  after  gastric  ulcer,  420 
after  operation,  114 


INDEX 


793 


Diet  before  operation,  350 

in  acute  inflammation,  117 

in  chronic  inflammation,  117 

in  severe  injuries,  117 
Digital  evacuation  of  rectum,  147 
Digitalis  in  shock,  91 
Diphtheria  antitoxin  for  hemophilia,   26S, 

269 
Diplococcus     intracellularis     meningitidis, 

dosage,  768 
Dislocation,  recurrent,  of  shoulder,  589 
Distention,  151 

paralytic,  152 

puncture  of  intestine  for,  155 
Dosage  of  vaccine,  guidance  to,  643 

of  vaccines,  table,  768,  770 
Douche-hammock,  356 
Drain,  how  to  remove,  217 

in  case  of  doubt,  215 

when  to  remove,  216 
Drainage  by  cigarette,  220 

by  gauze,  218 

by  glass  tube,  216 

by  rubber  tube,  217 

indications  for,  215 

methods  of  efficient,  225 

reasons  for,  214 

temporary,  214 
Dressing  under  anesthesia,  218 

wounds,  time  for,  209 
Dressing-tray,  212 
Drug  habits,  270 

poisoning,  256 
Duodenal  ulcer,  perforation  of,  421 
Duodenocholedochotomy,  435 
Dupuytren's  contraction,  571 

Eclampsia,  95,  507 

Eczema,  vaccine  treatment  of,  729 

Edema,  pulmonary,  after  ether,  167 

Effleurage,  316 

Egg  broth,  776 

Egg-nog,  hot,  776 

No.  I,  776 

No.  2,  776 
Eggs,  scrambled,  776 

soft-boiled,  776 
Ehrenfried's  club-foot  plaster,  593 
Elastic  bandage  for  hyperemia,  232 
Elaterin,  147 
Elbow,  excision  of,  574 
Electric  breeze,  342 
Electricity,  faradic,  346 


Electricity,  galvanic,  343 

static,  342 
Electrotherapy,  historic,  335 

indications,  336 

technique,  342 
Empyema,  thoracic,  404 

vaccine  treatment  of,  724 

subcutaneous,  407 
Endometritis,  489 
Enema,  cleansing,  122 

nutrient,  composition  of,  123,  124 
proprietary  preparation  in  124 
red  urine  in,  122 
size  of,  123 
technique,  120 
formulae,  125,  126 

technique  of  giving,  150 

drastic,  148 
Enemas,  mild,  148 
Enterorrhaphy,  427 
Enterostomy  under  cocaine,  157 
Enucleation  of  eye,  362 
Epididymitis,  527 
Epispadias,  516 
Epsom  salt,  146 

poisoning  by,  146 
Equinovarus,  593 
Erysipelas,  254 

vaccine  treatment  of,  727 
Eserin  salicylate  as  cathartic,  153 
Esophagotomy,  390 
Estlander's  operation,  409 
Ether  as  respiratory  irritant,  166 

drop  method,  28 

in  stomach  after  operation,  35 

pneumonia,  statistics,  168 
symptoms,  168 

rash,  253 

recovery,  duration  of,  31 
position  during,  32 

vomiting  after,  31 

Ochsner  treatment,  33 
olive  oil  treatment,  36 
Etherizing,  27 
Ethyl  chlorid,  27 
Excision  of  elbow,  574 

of  shoulder,  574 

of  wrist,  575 

of  hip,  575 

of  knee,  575 

of  vulva,  476 
Exstrophy  of  bladder,  546 
Extra-uterine  ])rcgnanc_\-,  502 


794 


INDEX 


Eye,  enucleation  of,  362 
Eyebrow,  preparation  of,  355 

Face,  plastic  operation  on,  363 
Facial  paralysis,  361 
Fallopian  tubes,  tuberculosis  of,  498 
Farabo.euf  amputation,  307 
Faradic  current,  346 
Fecal  fistula,  246 
causes  of,  247 
prophylaxis,  247 
treatment,  248 
Feeding  after  intubation,  389 
rectal,  120 
subcutaneous,  130 
Feet,  preparation  of,  357 

swelling  of,  312 
Femur,  fracture  of,  582 
Finger  contractures,  electric  treatment,  339 
Finsen  light  for  lupus,  750 
Fissure  in  ano,  548 
Fistula,  240 
fecal,  246 
in  ano,  548 
lymphatic,  245 
of  parotid,  361 
perineal,  527 
rectovaginal,  476 
suprapubic,  544 
treatment,  by  Beck's  paste,  241 
vesico-uterine,  507 
vesicovaginal,  475 
Flat-foot,  exercises  for,  312 
postoperative,  312 
shoe  for,  315 
Flatus,  151,  152 
Flaxseed  poultice,  228 
Flexible  shoes,  315 
Fomentations,  228 
Food  recipes,  774 
serving  of,  118 
Foods  as  cathartics,  144 
Foreign  bodies  left  in  abdomen,  286 
Formulae  for  nutrient  enemas,  125,  126 
Fowler  position,  24,  469 

relation  to  dilatation  of  stomach,  159 
Fractures,  compound,  576 
open,  576 

operative  fixation  of,  585 
French  heel  bandage,  190 
Friction,  317 
of  back,  319 
of  chest,  319 


Friction  of  foot,  318 

of  hands,  317 

of  hip,  319 

of  leg,  318 

of  neck,  319 

of  thigh,  319 
Fright,  preanesthetic,  98 
Frontal  sinus,  373 
Fulminating  infections,  vaccine  treatment 

of,  686 
Furuncle,  vaccine  treatment  of,  712 
Furunculosis,  vaccine  treatment  of,  713 

Gall-bladder  operations,  430 
Galvanic  current,  technique,  343 
Gamgee  dressing,  628 
Ganglion,  palmar,  570 
Gangrene,  poultice  for,  228 
Gant's  operation,  592 
Gartner's  canal,  abscess  of,  507 
Gas  bacillus  infection,  262 
Gasserian  ganglion,  360 
Gastrectasia,  157 
Gastrectomy,  415 
Gastric  dilatation,  acute,  157 

fistula,  feeding  in,  131 

paresis,  157 

ulcer,  diet  after,  420 
perforation,  418 
Gastro-enterostomy,  411 
Gastromesenteric  ileus,  157 
Gastroplication,  417 
Gastrotomy,  413 
Gauze  drainage,  218 
Gavage,  127 

indications  for,  127 
Gelatin  as  source  of  tetanus,  261 
General  peritonitis,  468 
Genital  tuberculosis,  vaccine  treatment  of, 

758 
Genito-urinary  surgery,  510 

tuberculosis,  vaccine  treatment  of,  758 
Glass  tube  drainage,  216 
Glycerin  as  a  dressing,  219 

enema,  147,  152 

suppository,  147 
Gonococcus,  dosage,  76S,  770 

vaccine,  preparation  of,  673 
Gonorrheal  arthritis,  vaccine  treatment  of, 

702 
Grafting,  572 

Granulations,  treatment  of  excessive,  241 
Gruel,  cracker,  777 


INDEX 


795 


Gruel,  flour,  777 

Indian-meal,  777 
and  flour,  777 

oatmeal,  777 

with  milk,  777 
Gum  chewing  for  parotitis,  264 
Gums,  antiseptic  for,  355 
Gunshot   wounds  of  abdomen,  437 

of  chest,  409 
Gypsum  for  bandages,  191 

Habit  pain,  336 

Habits,  270 

Hairy  areas,  preparation  of,  355 

Hallux  valgus,  597 

Hammock,  suspensory,  204 

Hands,  preparation  of,  357 

Hare-lip,  364 

asphyxia  after,  364 
Harrington's  solution,  354 
Headcrown  breeze,  technique,  342 
Heart,  massage  of,  92 
Heart-clot,  105 

Heat,  methods  of  appl}'ing,  226 
Heel,  bandage  of,  190 
Hematemesis,  38 
Hematoma,  pehic,  500 
Hemophilia,  266 

animal  serum  for,  267 

constitutional  treatment,  267 

treatment,  266 
Hemorrhage,  calcium  lactate  in,  68 

causes  of,  64 

constitutional  diathesis  in,  68 
treatment  of,  69 

delayed,  64 

diagnosis  of,  66 

internal  concealed,  65 

local,  treatment  of,  6g 

Monsell's  solution  for,  375 

nasal,  371 

operative  treatment  of,  66 

primary,  64 

secondary,  67 

summary  treatment  of,  70 

symptoms,  65 
Hemorrhoids,  550 
Hepaticodocholithotripsy,  436 
Hepaticodochostomy,  436 
Hepaticodochotomy,  435 
Hernia  cerebri,  359 

dressings,  439 

Cunningham,  201 


Hernia,  epigastric,  442 

femoral,  442 

in  children,  442 

incarcerated,  443 

inguinal,  439 

interstitial,  442 

obturator,  442 

postoperative,  291 

reduction  en  bloc,  447 

retroperitoneal,  442 

strangulated,  446 

umbilical,  442 

ventral,  442 
Hiccough,  causes,  179 

pathology,  179    ■ 

prognosis,  180 

treatment,  iSo,  181 
High  blood-pressure,  autocondensation  for, 

340 
High-frequency  current  for  sclerosis,  340 

technique,  342 
Highmore,  antrum  of,  372 
Hip,  excision  of,  575 
History  before  operation,  351 
Hoffa  table,  use  of,  583 
Hoffman's  anodyne  for  belching,  151 
Hot-air  treatment,  238 
Hot-water  bottles,  burns  from,  165 
Houston,  valves  of,  149 
Humerus,  fracture  of,  583 
Hydrocele,  injection  for,  516 

excision  of,  517 
Hydronephrosis,  532 
Hymen,  imperforate,  507 
H}'peremia,  methods  of  producing,  232 
Hypodermic  injection,  technique  of,  51 
Hypospadias,  516 
Hysterectomy,  abdominal,  499 

vaginal,  481 

Icterus  in  acetonemia,  177 
Iliac  thrombosis,  502 
Immunity,  active,  603 

duration  of,  after  vaccine  treatment,  715 

passive,  604 
Immunization,  principles  of,  601 
Imperforate  anus,  549 

hymen,  507 

rectum,  549 
Incandescent  light  therapy,  344 
Ingrowing  nail,  570 
Inguinal  bulxj,  570 
Innominate  artery,  ligations  of,  560 


796 


INDEX 


Inoculation,  antityphoid,  609 

focal  reaction,  659 

local  effects  of,  716 
reaction,  658 

site  for,  658 

sterilizing  syringe  for,  672 

technique  of,  769 
Insanity,  causes,  276 

forms,  277 

occurrence,  276 

postoperative,  276 

prognosis,  277 

treatment,  278 
Instruments  for  abdonainal  dressing,  209 

for  vaginal  dressing,  472 
Intestine,  acute  obstruction  of,  156 

puncture  of,  for  distention,  155 
Intubation,  382 

after-care,  388 

feeding  in,  132,  389 

indications  for,  383 

instruments  for,  385 

retained  tube,  389 

technique  for,  383 
Invalid  recipes,  774 
Inversion  of  uterus,  507 
Iodoform  poisoning,  257 
Irish  moss,  777 

Irrigating  a  sinus,  method  of,  242 
Irrigation,  hot,  227 
Ischiorectal  abscess,  549 

Jaitndice  after  chloroform,  177 

in  acetonemia,  177 
Jaw,  excision  of  lower,  360 

soreness  after  anesthesia,  164 
Jejunostomy,  427 

Johns  Hopkins  operation  for  hernia,  442 
Joint  adhesion,  electric  treatment,  339 
Joints,  tuberculosis  of,  vaccine  treatment  of, 

749 
vaccine  treatment  of,  700 
Junket,  777 
cocoa,  777 
egg,  778 

Keloid,  x-ray  treatment,  342 
Kidney  drainage,  permanent,  536 

fatty  degeneration  of,  after  chloroform, 
170 

operations  on,  533 

surgical,  533 
Klapp  suction-cups,  235 


Knee,  excision  of,  575 

operations  on,  588 

strapping,  202 
Knock-knees,  592 
Kollmann  dilator,  519 
Kraske  operation,  150,  553 

LAillNECTOMY,  598 

Laryngeal  operations,  feeding  in,  131 
Laryngotomy,  381 
Lavage,  technique,  127,  128 
Layout  for  abdominal  dressing,  209 
Lemonade,  flaxseed,  778 

with  egg,  778 
Licorice  powder,  145 
Ligation  of  carotid  artery,  561 

of  external  Uiac  artery,  562 

of  femoral  arter}^,  562 

of  innominate  artery,  560 

of  subcla\ian,  561 

of  ureter,  501 
Light  therapy,  technique,  344 
Limbs,  artificial,  307 
Lime-water,  778 
Lithotomy,  perineal,  545 
Littauer-Paynes  scissors,  212 
Liver,  abscess  of,  428 

acute  yellow  atrophy  of,  176 

hydatid  cyst  of,  429 

post-anesthetic  degeneration  of,  174 

superfatted,  174 

action  of  chloroform  on,  174 
Locke's  solution,  113 
Lund  swathe,  198 
Lupus,  treatment  by  Finsen-ray,  750 

vaccine  treatment,  749 
Lymphatic  fistula,  245 
Lymph-nodes  of  neck,  396 

Magnesitjm  sulphate  for  tetanus,  262 
Malta  fever,  697 
Many-tailed  bandage,  200 
Massage,  316 

of  abdomen,  325 

of  arm,  322 

of  back,  324 

of  chest,  325 

of  feet,  322 

of  fingers,  321 

of  heart,  92 

of  leg,  323 

of  thigh,  323 
Mastoid  operation,  preparation  for,  355 


INDEX 


797 


Mastoiditis,  398 
Matas'  operation,  563 
Mattress,  18 
Maydl's  operation,  547 
McArthur's  operation,  442 
McBurney  incision,  454 
hernia  after,  461 
no  drainage,  455 
temporary  drainage,  458 
with  abscess,  458 
Meatotomy,  515 
Medicinal  rash,  256 
Membrane,  Cargile,  299 
Menopause,  psychoses  in,  278 
Mercury,  idiosyncrasy  to,  256 
Micrococcus  catarrhalis,  76S 

neoformans,  dosage,  76S 
Mikulicz  tampon,  221 
Milk  and  albumen,  778 

and  molasses  enema,  148 

and  water,  hot,  778 

peptonized,  cold  process,  778 

immediate  process,  778 

sago,  778 

milk-punch,  778 
Miscarriage,  484 
JMorphin  habit,  271 
Mosetig-Moorhof's  bone-wax,  592 
Mouth  cleanliness  before  operation,  350 

gag,  30 

preparation  of,  355 

washing  for  thirst,  42 
IMurphy's  button,  427 
Muscle  atrophy,  treatment,  338 

suture  of,  565 
Mutton  broth,  775 
M3'ocarditis  after  fibroids,  502 
Myomectomy,  507 

Nail,  ingrowing,  570 
Nailing  fractures,  585 
Nasal  adhesions,  371 

feeding,  129 

polypi,  371 

spurs,  371 

hemorrhage,  371 
Nausea,  32 
Neck,  abscess  of,  397 

carbuncle  of,  397 

lymph-nodes  of,  396 

operations  on,  378 
Negative  phase,  611 
Nephrectomy,  539 


Nephritis  after  anesthesia,  169 

after  chloroform,  170 

post -operative,  statistics,  169 
treatment,   171 
Nephrorrhaphy,  541 
Nephrotomy,  533 

apparatus,  536 

double,  534 
Nerve  anastomosis,  567 

cocainization  to  prevent  shock,  86 

injury,  electric  treatment,  33S 

suture,  566 
Neurasthenia,  postoperative,  electric  treat- 
ment, 340 
Neuritis,  pressure,  33S 
Nitrous  oxid,  27 
Noma,  351 

Nose,  preparation  of,  356 
Nurse's  chart,  21 

instruments,  21 
Nutrient  enema,  123 

Obstruction,  acute  intestinal,  156 

mechanical,  of  intestine,  156 

septic,  of  intestine,  156 

symptoms  of,  157 

when  to  operate,  157 

whether  to  operate,  157 
Obstructive  h3^eremia,  232 
Ochsner  treatment  of  ether  vomiting,  33 
O'Dwyer  cannula,  384 
Oil  injection  of  urethra,  513 

sterilization,  672 
Olecranon,  fracture  of,  588 
Olive  oil  as  laxative,  145 

for  adhesions,  299 
Open  fractures,  576 
Ophthalmic  reaction,  733 
Opsonic  incubator,  677 

index  and  symptoms,  correlation  of,  648 
formula  of,  608 
normal  variations,  613 
technique  of,  675 
theory  of,  608 
Opsonins,  definition  of,  605 

origin  of,  606 
Osteomyelitis,  590 

acute,  591 

chronic,  592 

subacute,  591 

vaccine  treatment  of,  725 
Osteoplastic  resection  of  skull,  359 
Ovarian  cysts,  493 


798 


INDEX 


Ovariotomy,  493 
Ovary,  resection  of,  493 
Overdosage  of  vaccines,  654 
Oyster  broth,  775 

Packard's  suprapubic  drainage,  531 
Pain,  47 

cicatricial,  337 

congestive,  337 

habit,  2,3^^ 

treatment  by  vacuum  tube,  343 
Painful  stump,  558 
Palmar  ganglion,  570 
Pancreas,  wounds  of,  448 
Pancreatic  cyst,  448 
Pancreatitis,  acute,  447 
Paquelin  cautery  for  paresis  of  bowels,  153 
Paraffin  prosthesis,  370 
Paralysis,  postanesthetic,  165 
Paralytic  distention,  152 
Paresthesia,  electric  treatment,  340 
Parkhill  clamp,  585 
Paronychia,  570 
Parotid  fistula,  361 

tumors  of,  361 
Parotitis,  263 

causes  of,  264 

suppuration  in,  264 

treatment,  264 
Passive  immunity,  604 

motions,  329 
Patella,  fracture  of,  587 
Pelvic  abscess,  478 

hematoma,  500 
Penis,  operations  on,  510 
Percussion  movements,  327 
Perforation  of  uterus,  489 
Pericardium,  operations  on,  409 
Perineal  drainage-tube,  528 

dressing  (Cunningham),  206 
home -method  for,  514 

fistula,  527 

prostatectomy,  528 
Perineorrhaphy ,_  471 

complete,  473 
Perionychia,  570 
Peritoneum,  drainage  of,  215 

tuberculosis  of,  498 
Peritonitis,  castor  oil  into  intestine  for,  154 

general,  46S 
Peritonsillar  abscess,  377 
Petrissage,  316 
Pfannensteil's  incision,  292 


Phagocytic  variations,  612 

Phases,  sequence  of,  612 

Phenol  poisoning,  257 

Phenolphthalein,  145 

Phlebitis,  portal,  466 

Phlegmon,  vaccine  treatment  of,  689 

Physical  examination  before  operation,  351 

Picric  acid  poisoning^  258 

Pillows,  18 

Pinching,  327 

Pirogoff  amputations,  307 

Plaster   jacket   causing  gastric   dilatation, 

160 
Plaster-of-Paris  bandage,  191,  192,  193, 194 
Plastic  operations  on  face,  363 
Pneumococcus,  768 
dosage,  770 

vaccine,  preparation  of,  673 
Pneumonia  after  anesthesia,  166 

postoperative,  causes  of,  168 
Poisoning,  iodoform,  257 
carbolic  acid,  257 
phenol,  257 
picric  acid,  258 
Polypi,  nasal,  371 
Porro  operation,  505 
Portal  phlebitis,  466 
Position,  Fowler,  24 
Positive  phase,  611 
Possett  treacle,  778 
Posterior  wire  splint,  579 
Postoperative  flat-foot,  312 
hernia,  prophylaxis,  292 
symptoms,  293 
treatment,  294 
Posture,  dorsal,  23 
Fowler,  24 
Rose,  377 
semiprone,  24 
Poultices,  228 

Pregnancy,  extra-uterine,  502 
Preparation  of  patient,  348 
Pressure  neuritis,  338 
Proctectomy,  vaginal,  557 
Proctoclysis,  42 

apparatus  for,  43  . 

Prolapse  of  rectum,  553 
Prostatectomy  perineal,  528    • 

suprapubic,  530 
Prostatic  abscess,  532 
Prostatotomy,  532 
Prosthesis,  paraffin,  370 
Provisional  sutures,  214,  219 


INDEX 


799 


Psoas  abscess,  569 

Psychoses,  postoperative,  273 

Pubiotomy,  492 

Puerperal  sepsis,  vaccine  treatment  of,  694 

Pulmonary  edema  after  ether,  167 

embolism,  10 1 
mortality  of,  102 
operative  treatment,  104 
prophylaxis,  103 
symptoms,  102 
treatment,  103 
Pulse,  52 

force  of,  54 

irregular,  54 

irregularity  of,  54 

rate,  53 

rhythm,  54 

tension  of,  56 

volume  of,  56 
Puncture  of  intestine  for  distention,  ^55 
Pyemia,  250 
Pylephlebitis,  106 

diagnosis  of,  107 

pathology  of,  106 

prognosis  of,  107 
Pylorectomy,  418 

Quinsy,  377 

Rabbit  serum  for  hemophilia,  268 
Radium  therapy,  347 
Ranula,  368 
Rash,  ether,  253 

medicinal,  256 

septic,  253 
Raw-meat  sandwich,  778 
Recipes  for  the  sick,  774 
Recovery  room,  35 
Rectal  feeding,  120 
indications,  120 
technique,  120 

plug,  220 

suppository  of  foods,  125 

lube  for  flatus,  152 
Rectocele,  471 
Rectovaginal  fistula,  476 
Rectum,  cancer  of,  553 

digital  evacuation  of,  147 

imperforate,  549 

operations  on,  550 

preparation  of,  357 

prolapse  of,  553 

stricture  of,  551 


Rectus  incision,  drainage,  460 

hernia  after,  461 
Recurrent  bandage  of  head,  195 
Red  screen,  therapy,  344 
Reduction  en  bloc,  447 
Relief  of  pain  by  electricity,  336 
Remedial  movements,  328 
Removal  of  stitches,  210,  212,  213 
Resistive  motions,  330 
Respiration,  63 

artificial,  109 
Rest  and  pain,  226 

as  treatment,  225 
Restlessness,  39 
Resuscitation  by  oxygen,  112 

by  electricity,  112 
Retropharyngeal  abscess,  377 
Retroversion  of  uterus,  493 
Reverdin  grafts,  573 

for  bed-sores,  285 
Ribs,  strapping,  201 
Ringer's  solution,  113 
Robson's  bone-bobbin,  428 
Rochelle  salt,  146 
Rogers'  serum,  395 
Rontgen  ray.     See  X-ray. 
Rose  position,  377 
Rubber  tube  drainage,  217 
fenestrated,  220 
inverted,  220 
Ruptured  urethra,  528 


Saline  infusion,  45 
rectal,  42 

solution,  45 
Salpingitis,  tuberculous,  498 
Salpingo-oophorectomy,  495 
Salt  and  citrate  solution  (Wright),  632 
Sarcoma,  Coley  treatment,  771 
Scalp,  preparation  of,  355 

wounds,  aseptic,  358 
septic,  358 

with  necrotic  bones,  35S 
Scar,  electric  treatment,  338 
Scarlatina,  surgical,  255 
Schedc's  operation,  409 
Scissors  for  stitches,  212 
Scrotum,  operations  on,  516 
Scrubbing,  353 
Scidlitz  powder,  146 
Septic  rash,  253 

wounds,  treatment,  225 


8oo 


INDEX 


Septicemia,  250 

vaccine  dosage  in,  699 
treatment  of,  693 
Septico metastasis,  251 
Septicopyemia,  250 
causes,  250 
diagnosis,  251 
prognosis,  251 
symptoms,  251 
treatment,  252 
Serum,  Beebe's,  395 

Coley's,  771 
Shock,  adrenalin  in,  87 
causes,  82 
definition,  82 
elastic  suit  of  Crile,  89 
experimental  investigations,  S3 
hypodermoclysis  in,  89 
intravenous  infusion  in,  90 
massage  of  heart  in,  92 
prophylaxis,  85 
stimulating  enema,  93 
sjinptoms,  84 
treatment,  84 

by  drugs,  88,  91 
urethral,  140 
Shoes,  flexible,  315 
Shoulder,  excision 'of,  574 
Sick-room,  17 

furniture,  18 
Sinus,  frontal,  373 
Sinuses,  240 

tuberculous,  vaccine  treatment  of,  743 
vaccine  treatment  of,  726 
Sipping,  116 
Skin-grafting,  572 
Skull  operations,  358 
Sling,  203 

double,  203 
Slipping  of  pedicle  Ugature,  494 
Smith  splint,  582 

Soda  bicarbonate  in  acetonemia,  178 
Sound,  technique  of  passing,  522 
Soup,  rice,  779 

white  celery,  779 
Spark,  technique,  342 
Spica  bandage,  189 
of  hip,  189 
of  shoulder,  190 
Spina  bifida,  597 
Spine,  fracture  of,  599 
Spiral  drain,  220 

reverse  bandage,  189 


Spirochceta  gracilis,  351 

Splenectomy,  450 

Split  rubber  drain,  220 

Spurs,  nasal,  371 

Stab  wounds  of  chest,  409 

Standardization  of  a  vaccine,  663 

Staphylococcus,  dosage,  768,  770 

vaccine,  preparation  of,  660 
Static  electricity,  342 
Status  lymphaticus,  98,  265 
Stauungs-h}'peremie,  232 
Sterilization  by  oil,  672 
Stimulation  before  operation,  351 
Stitch  abscess,  221 

intracuticular,  213 

scissors,  212 
Stitches,  removal  of,  210 
Stockings,  right  and  left,  597 
Stomach,  acute  dilatation  of,  154,  157 
causes,  158 
f  requeue}-,  158 

dilatation,  "relation  of  Fowler  position  to, 

159 
Strapping  abdominal  wound,  201 

ankle,  201 

knee,  202 

ribs,  201 
Streptococcus,  dosage,  768,  770 

vaccine,  preparation  of,  673 
Strophanthin  in  shock,  92 
Strj-chnin  for  paresis  of  bowels,  153 
Stump  bandage,  195 

painful,  558 

shrinkage  of,  311 
Stump-corset,  311 
Subcutaneous  feeding,  130 
Subdiaphragmatic  abscess,  107 
Subphrenic  abscess,  107,  462 

after  appendicitis,  464 
Succussion  in  acute  gastric  dilatation,  160 
Sucker-drainage,  216 
Suction-cups,  235 
Suction-pump,  237 
Sudden  death,  97 
Sunlight  in  convalescence,  281 
Superheated  dry  air,  therapy,  345 
Suppression  of  urine,  510 
Suprapubic  cystotom}-,  543 

fistula,  544 

prostatectomy,  530 
Surgical  kidney,  533,  545 

scarlatina,  255 
Suspensory  bandages,  203 


INDEX 


8oi 


Suspensory  bandages,  adhesive  plaster,  205 
Suture,  arterial,  562 

of  brachial  plexus,  567 

of  muscle,  565 

of  nerve,  566 

of  tendon,  565 
Suturing  fractures,  585 
Sycosis,  vaccine  treatment  of,  728 
Syme's  amputations,  307 
Symphysiotomy,  490 
Synovial  fringe  of  knee,  588 
Swathes,  200 

abdominal,  301 
Sweating,  40 
Sweetbreads,  779 

Tamaeind-watee,  779 
Tapotement,  316 
T-bandage,  200 
Tea,  779 

corn,  779 

habit,  272 
Technique,  electrotherapeutic,  342 

of  a  dressing,  212 
Temperature,  58 

after  hemorrhage,  59 

aseptic,  58 

in  sepsis,  61 

in  shock,  59 

intercurrent  causes  of,  62 
Tendon,  suture  of,  565 

transplantation,  566 
Tenosynovitis,  tuberculous,  570 
Testicles,  bandage  to  elevate,  203 
Testis,  gangrene  of,  517 

undescended,  518 
Testudo  bandage  of  heel,  191 
Tetanus,  259 

causes,  259 

relation  of  rectal  operations  to,  260 

treatment,  261 
Therapy,  light,  344 
Thiersch  grafts,  572 
Thirst,  41 

treatment  of,  42 
Thoracic  duct,  injury  of,  245 

fistula  of,  245 
Thoracoplasty,  409 
Thorax,  operations  on,  401 
Thrombophlebitis,  99 

prophylaxis,  100 

symptoms  of,  100 

treatment  of,  loi 
51 


Thrombosis,  etiology,  99 

iliac,  502 
Throttled  pipet,  682 
Throttling  the  belly  for  hiccough,  180 
Thyroidectomy,  partial,  390 

anesthesia  in,  390 
Thyroidism,  393 
Thyrotoxicosis,  391   « 

serum  treatment,  395 
Time  for  dressing  wounds,  209 
Toast,  milk,  779 

peptonized  milk,  779 
Toast-water,  779 
Tobacco  habit,  272 

Toe  contractures,  electric  treatment,  339 
Tongue,  coating  of,  183 

forceps,  30 

rhythmic  traction  of,  112 

significance  of,  182 

soreness,  after  anesthesia,  164 
Tonics,  281 
Tonsils,  enlarged,  375 

tumors  of,  376 
Town  treatment  for  alcohol,  271 
Tracheal  tube,  removal  of,  379 
Trachelorrhaphy,  483 
Tracheotomy,  378 

technique  of,  37 
Transfusion,  70 

arrangement  of  operating  room,  78 

general  management  of  a,  77 

history  of,  71 

technique,  73 

the  donor,  77 

the  recipient,  77 
Trendelenburg  position  and  pneumonia,  168 
Trephining,  358 

Truss  after  hernia  operations,  442 
Tubal  pregnancy,  502 
Tuberculin,  choice  of,  737 

dosage,  747,  768,  770 

methods  of  giving,  737 

preparation  of,  673 

treatment  of,  673 
prognosis,  751 
Tuberculosis,    genital,    vaccine   treatment, 
758 

localized,  vaccine  treatment  of,  731 

renal  and  vesical,  754 
vaccine  treatment,  751 

vesical,  756 
Tuberculous  lymph-nodes,  prognosis,  744 
x-ray  treatment,  342 


802 


INDEX 


Tuberculous   lymphnoditis,   vaccine   treat- 
ment of,  739 

peritonitis,  49S 

salpingitis,  498 

tenosyno\dtis,  570 
Tubes,  resection  of,  493 
Turpentine  as  carminative,  152 

compound  enemas  of,  149 

stupes  for  flatus,  153 
Tympanitis,  153,  154 

importance  of  diagnosis,  154 
Typhoid,  inoculation  against,  609 

vaccine,  preparation  of,  673 

Ulcer  of  duodenum,  perforation,  421 

of  stomach,  perforation,  418 
Uremia,  96 
Uremic  coma,  95 
Ureter,  accidental  ligation  of,  501 

kink  in,  542 

operations  on,  543 
Urethra,  preparation  of,  357 

rupture  of,  528 
Urethral  caruncle,  excision  of,  477 

shock,  140 
Urethrotomy,  external,  519 

internal,  51S   • 
Urinal,  female,  546 

male,  530 
Urinalysis,  importance  of,  511 
Urinary  fever,  acute,  140 
chronic,  140 
drainage  for,  142 

fistula,  persistent,  536 
Urine  before  operation,  351 

suppression  of,  510,  539 
Uterine  sepsis,  vaccine  treatment  of,  694 
Uterus,  atresia  of,  506 

inversion  of,  507 

perforation  of,  489 

retroversion  of,  493 

Vaccine,  bacterial,  definition  of,  610 
bottling  of,  669 
definition  of,  660 
galactose-killed,  768 
keeping  quahties  of,  668 
laborator}'  technique,  660 
preparation  of,  659 
standardization  of,  663 
summary  of,  indication  for,  643 
therapy,  dangers  of,  650 
treatment,  diagram  of,  607 


Vaccine  treatment  of  acne,  718 
of  antrum  disease,  725 
of  carbuncle,  719 
of  eczema,  729 
of  empyema,  724 
of  erysipelas,  727 
of  fulminating  infections,  686 
of  furuncle,  712 
of  furunculosis,  713 
of  gonorrheal  arthritis,  702 
of  infectious  arthritis,  700 
of  lupus,  749 
of  osteom3^elitis,  725 
of  phlegmon,  689 
of  puerperal  sepsis,  694 
of  renal  tuberculosis,  751 
of  septicemia,  693 
of  sinuses,  726 
of  suppurative  arthritis,  707 
of  sycosis,  728 
of  tuberculosis  of  bones,  748 
of  tuberculous  joints,  749 
h-mphnoditis,  739 
sinuses,  743 
of  uterine  sepsis,  694 
^'accines,  case  of  overdosage,  656 
frequency  of  dosage,  653 
living,  765 

new  methods  of  preparation,  764 
overdosage,  654 

serious  results  from,  656 
sterilization  of,  685 
table  of  dosage,  768,  770 
Vacuum  tubes,  technique,  343 
Vagina,  atresia  of,  506 

preparation  of,  356 
Vaginal  h}-sterectomy,  481 
cyst,  507 
cystostomy,  545 
douche,  method  of,  356 

position,  472 
drains,  219 
proctectomy,  557 
section  for  abscess,  478 
for  appendages,  480 
Valve  of  Gerlach,  452 
Varicocele,  517 

Varicose  eczema,  vaccine  treatment  of,  729 
ulcer,  vaccine  treatment  of,  730 
veins,  564 

bandage  for,  191 
\'arnish,  antiseptic,  363 
\'eins,  varicose,  564 


INDEX 


803 


Velpeau  bandage,  196 

modified,  197 
Ventrofixation,  493 
Ventrosuspension,  493 
Vesico-uterine  fistula,  507 
Vesicovaginal  fistula,  475 
Vibration  therapy,  345 
Vicious  circle  vomiting,  412 
Vomiting,  32 

Bier  treatment,  37 

champagne  for,  37 

drug  treatment,  37 

gastric  lavage  for,  36 

heat  and  cold  for,  37 

in  vicious  circle,  412 

of  blood,  38 
Von  Pirquet  reaction,  732,  733 
Vulva,  excision  of,  476 
Vulvovaginal  abscess,  477 

Water  bed,  18 

Water-drinking  before  operation,  350 


Watson's  nephrotomy  apparatus,  536 

perineal  button,  520 
drainage-tube,  528 
Wave-current,  technique,  342 
Weak  foot,  312 
Weir's  operation,  556 
Whitehead's  operation,  150,  552 
Wick,  method  of  inserting,  243 
Wine,  mulled,  779 

whey,  779 
Wiring  fractures,  585 
Wolf  grafts,  573 
Worsted  truss,  443 
Wounds,  signs  of  sepsis,  223 

time  for  dressing,  209 
Wright's  citrate  and  sahne,  229 
Wrist,  excision  of,  575 


X-RAY  treatment  of  cancer,  341 
of  keloid,  342 
of  tuberculous  lymph-nodes,  342 


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University  of  Pennsylvania  Medical  Bulletin 

"Upon  reading  through  the  contents  of  this  book  we  are  impressed  by  the  remarkable 
fulness  with  which  it  reflects  the  notable  contributions  recently  made  to  ophthalmic  literature. 
No  important  subject  within  its  province  has  been  neglected." 

Johns  Hopkins  Hospital  Bulletin 

"No  single  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainly  one  of  the 
best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 


SAUiYDERS'    BOOKS    ON 


Brtihl,  Politzer,  and  Smith's 
Otology 


Atlas  and  Epitome  of  Otology.  By  Gustav  Bruhl,  M.  D.,  of 
Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer,  of 
Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith,  M.D.,  Pro- 
fessor of  Otology  in  the  Jefferson  Medical  College,  Philadelphia. 
With  244  colored  figures  on  39  lithographic  plates,  99  text  illustra- 
tions, and  292  pages  of  text.  Cloth,  $3.00  net.  Ifi  Saimders'  Hand- 
Atlas  Series. 

INCLUDING  ANATOMY  AND  PHYSIOLOGY 

The  work  is  both  didactic  and  clinical  in  its  teaching.  A  special  feature  is 
the  very  complete  exposition  of  the  minute  anatomy  of  the  ear,  a  working  knowl- 
edge of  which  is  so  essential  to  an  intelligent  conception  of  the  science  of  otology. 
The  association  of  Professor  Politzer  and  the  use  of  so  many  valuable  specimens 
from  his  notably  rich  collection  especially  enhance  the  value  of  the  treatise.  The 
work  contains  everything  of  importance  in  the  elementary  study  of  otology. 

Clarence  J.  Blake,  M.  D., 

Professor  of  Otology  in  Harvard  University  Medical  School,  Boston. 

"  The  most  complete  work  of  its  kind  as  yet  published,  and  one  commending  itself  to  both 
the  student  and  the  teacher  in  the  character  and  scope  of  its  illustrations." 

Haab  and  deSchweinitz*s 
Operative  Ophthalmology 

Atlas  and   Epitome  of    Operative    Ophthalmology.       By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  de  Schweinitz, 
M,  D.,  Professor  of  Ophthalmology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  154  text-cuts,  and  375  pages  of 
text.     In  Saunders'  Hand-Atlas  Series.     Cloth,  $3.50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  will  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author's  thirty 
years'  experience  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  Recognizing 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures,  Dr.  Haab  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 

Johns  Hopkins  Hospital  Bulletin 

"  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  can  well 
hold  place  with  more  pretentious  text-books." 


DISEASES    OF   THE  EYE. 


Haab  and  DeSchweinitz*s 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
1 01  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 
text.     Cloth,  $3.00  net.     In  Smmdcrs'  Hand-Atlas  Scries. 

THE   NEW    (3d)    EDITION 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  so  compHcated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ;^3.oo  net.     In  Saiindcrs'  Hand-Atlas  Series. 

THE  NEW   (2d)    EDITION 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet.  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


SAUNDERS'   BOOKS  ON 


Cradle's 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern  Uni- 
versity Medical  School,  Chicago.  Handsome  octavo  of  547  pages, 
illustrated,  including  two  full-page  plates  in  colors.     Cloth,  $l.^Q  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume  presents  diseases  of  the  Nose,  Pharynx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medical  Journal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusion 
incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  797  pages;  with  219  illustrations,  26  in  colors. 
Cloth,  ^4.00  net;  Half  Morocco,  ^5.50  net. 

THE    NEW   (4th)    EDITION 

Four  large  editions  of  this  excellent  work  fully  testify  to  its  practical  value. 
In  this  edition  the  author  has  revised  the  text  thoroughly,  bringing  it  absolutely 
down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  extended  con- 
sideration has  been  given  to  treatment,  each  disease  being  considered  in  full,  and 
definite  courses  being  laid  down  to  meet  special  conditions  and  symptoms. 
Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in  vain 
for  anything  he  needs." 


EYE,    EAR,    NOSE,    AND    THROAT. 


GET  ^  •  THE  NEW 

THE    BEST  I^  lit  6  It  1  C  Si  11  STANDARD 


American 
Illustrated   Dictionary 


The  New  (5th)  Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  loo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
DoRLAND,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  876  pages,  bound  in  full  flexible  leather. 
Price,  1^4.50  net;  with  thumb  index,  ;^5.oo  net. 

A   KEY  TO   MEDICAL  LITERATURE— WITH  2000   NEW  TERMS 

In  this  edition  the  book  has  been  subjected  to  a  thorough  revision.  The 
author  has  also  added  upward  of  two  thousand  important  new  terms  that  have 
appeared  in  medical  literature  during  the  past  few  months. 

Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University ,  Baltimore 

"  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  550pages,  with  219 text-cuts  and  several  colored 
plates.     Cloth,  ^4.50  net ;  Half  Morocco,  ^6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  specialist  ; 
but  Dr.  Theobald  in  his  book  has  described  very  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  withm  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner. 

Charles  A.  Oliver,  M.D.. 

Clinical  Professor  of  Ophthalmology,    Woman's  Medical  College  of  Pennsylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  Most 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


8  EYE,    EAR,    NOSE,    AND    THROAT. 

deSchweinitz    and    Holloway   on   Pulsating    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  ^2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

British  Medical  Journal 

"  The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  oi 
the  disease  will  be  found." 

Jackson     on     the     Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  woi-k." 

Grant  on  Face,   Mouth,   and  Jaws 

A  Text-'Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Friedrich   and   Curtis   on  Nose,   Larynx,  and   Ear 

RhINOLOGY,   LARYNGOLOGy,  AND    OtOLOGY,    AND   ThEIR    SIGNIFICANCE 

IN  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited 
by  H.  Holbrook  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York 
Nose  and  Throat  Hospital.  Octavo  volume  of  350  pages.  Cloth, 
^2.50  net. 


GENITO-URINARY  AND    NOSE,     THROAT,     ETC.  9 

Greene  and  Brooks* 
Genito-Urinary  Diseases 

Diseases  of    the   Qenito=Urinary  Organs  and  the  Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University ;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  605  pages,  illustrated.  Cloth,  ^5.00  net;  Half 
Morocco,  $6.50  net. 

THE  NEW     (2d)     EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinary 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Clinical  Professor  of  Otology, 
Medico-Chirurgical  College,  Philadelphia.  i2mo  of  556  pages,  pro- 
fusely illustrated.     Flexible  leather,  $2.50  net. 

FOR    PRACTITIONERS 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  are. few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Genito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  5kin.  Edited  by  L.  Bolton  Bangs,  M.  D.,  and 
W.  A.  Hardaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  ^7.00  net. 


SAUNDERS'    BOOKS    ON 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Octavo  of  1180  pages,  with  280  text-cuts  and 
32  plates.     Cloth,  ^6.00  net ;   Half  Morocco,  $7.50  net. 

JUST  READY— THE  NEW  (6th)  EDITION 

The  demand  for  five  editions  of  this  work  in  a  period  of  five  years  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  new 
subjects  include  Verruga  Peruana,  Leukemia  Cutis,  Meralgia  Paraesthetica,  Dhobie 
Itch,  and  Uncinarial  Dermatitis, 

George  T.  Elliot,  M.  D.,  Professor  of  Dermatology,  Coj-nell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment,' 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  think  it  holds  first  place." 


Schamber^'s  Diseases  of  the  Skin 
and  f^ruptive  Pevers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay  F.  Schamberg, 
M.  D.,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  534  pages,  illustrated.      Cloth,  1^3.00  net. 

THE  CUTANEOUS   MANIFESTATIONS   OF  ALL  DISEASES 

"  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied. these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  .  The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment." — American  Journal 
of  Medical  Sciences. 


DISEASES   OF   THE  SKIN. 


Mracek  and  Stelwa^on*s 
Diseases  of  the  Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W.  Stelwagon, 
M.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  yy  colored  plates,  50  half-tone  illustrations,  and 
280  pages  of  text.     I?t  Saunders''  Hand-Atlas  Series.  Clo.,  ;g4.oonet. 

THE    NEW    (2d)    EDITION 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  contains, 
together  with  colored  plates  of  unusual  beauty,  numerous  illustrations  in  black, 
and  a  text  comprehending  the  entire  field  of  dermatology.  The  illustrations  are- 
all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic,  and  the  execution 
of  the  plates  is  superior  to  that  of  any,  even  the  most  expensive,  dermatologic 
atlas  hitherto  published. 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are : 
First,  its  handiness ;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color,  and  the 
diagnostic  points  which  they  bring  out." 

Mracek  and  Bangs' 
Syphilis  and  Venereal 

Atlas    and    Epitome   of    Syphilis    and    the    Venereal    Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito-Urinary  Surgery,  Univer- 
sity and  Bellevue  Hospital  Medical  College,  New  York.  With  71 
colored  plates  and  122  pages  of  text.  Cloth,  $3.50  net.  In  Saunders' 
Hand-Adas  Series. 

CONTAINING   71   COLORED   PLATES 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom  the 
original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty  anything 
of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Germany,  but 
throughout  the  literature  of  the  world. 

Robert  L.  Dickinson.  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 
"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and  graphic 
character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and   the   Venereal  Diseases.'     I  know  of 
nothing  in  this  country  that  can  compare  with  it." 


12  SAUNDERS'  BOOKS   ON 

Holland's  Medical 
Chemistry  and  Toxicology 

A  Text=Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.D.,  Professor  of  Medical  Chemistry  and  Toxicology, 
and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo  of  655 
pages,  fully  illustrated.     Cloth,  $3.00  net. 

THE  NEW  (2d)   EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  tO' 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistn-  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.     More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse ;  its  illustra.tions  well  chosen;  its  development  logical,, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Grtinwald  and  Newcomb*s 
Mouth,  Pharynx,  and  Nose 

Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Pharynx,  and 
Nose.  By  Dr.  L.  Grunwald,  of  Munich.  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  James  E. 
Newcomb,  M.  D.,  Instructor  in  Laryngology,  Cornell  University  Medical 
School.  With  102"  illustrations  on  42  colored  lithographic  plates,  41 
text-cuts,  and  219  pages  of  text.  Cloth,  ;$3.oo  net.  In  Saunders* 
Hand-Atlas  Series. 

INCLUDING   ANATOMY   AND   PHYSIOLOGY 

In  designing  this  atlas  the  needs  of  both  student  and  practitioner  were  kept 
constantly  in  mind,  and  as  far  as  possible  typical  cases  of  the  various  diseases 
were  selected.  The  illustrations  are  described  in  the  text  in  exactly  the  same  way 
as  a  practised  examiner  would  demonstrate  the  objective  findings  to  his  class. 
The  illustrations  themselves  are  numerous  and  exceedingly  well  executed.  The 
editor  has  incorporated  his  own  valuable  experience,  and  has  also  included  exten- 
sive notes  on  the  use  of  the  active  principle  of  the  suprarenal  bodies. 

American  Medicine 

"  Its  conciseness  without  sacrifice  of  clearness  and  thoroughness,  as  well  as  the  excellence 
of  text  and  illustrations,  are  commendable." 


URINE  AND   IMPOTENCE.  13 

O^den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ;$3.00  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Vecki*s  Sexual  Impotence 


The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecki,  M.  D.  From  the  Second  Revised  and  Enlarged  German 
Edition.      i2mo  volume  of  329  pages.     Cloth,  ^2.00  net. 

THIRD  EDITION,  REVISED  AND  ENLARGED 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  its  pre-eminent  importance  deserves,  and  this  volume  will 
come  to  many  as  a  revelation  of  the  possibilities  of  therapeutics  in  this  important 
field.  The  reading  part  of  the  English-speaking  medical  profession  has  passed 
judgment  on  this  monograph.  The  whole  subject  of  sexual  impotence  and  its 
treatment  is  discussed  by  the  author  in  an  exhaustive  and  thoroughly  scientific 
manner.  In  this  edition  the  book  has  been  thoroughly  revised,  and  new  matter 
has  been  added,  especially  to  the  portion  dealing  with  treatment. 

Johns  Hopkins  Hospital  Bulletin 

"  A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The  treatment 
of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and  judicious." 


14  SAUNDERS'    BOOKS   ON 

Wells'   Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  549  pages. 
Cloth,  $1.2^  net;  Half  Morocco,  ^4.75  net. 

Dr.   Wells  here  concisely   presents   the  latest  work    systematically  con- 
sidering the  subject  of  general  pathology  from  the  standpoint  of  the  chemical 
processes  involved.      Special  chapters  are  devoted  to  Diabetes  and  to  Uric- 
acid  Metabolism  and  Gout. 
Wm.  H.  Welch,  M.  D.,  Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


The  New  (2d)  Edition 


Saxe's  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
Instructor  in  Genito-Urinary  Surgery,  York  Post-graduate  Medical 
School  and  Hospital.  i2mo  of  448  pages,  fully  illustrated. 
Cloth,  ;^i.75  net. 

This  work  is  intended  as  an  aid  in  diagnosis,  by  interpreting  the  clinical 
significance  of  the  chemic  and  microscopic  urinary  findings. 

Francii  Carter  Wood,  M.  D.,    Adjmtct  Professor  of  Clinical  Pathology,   Columbia    Uni- 
versity. 

"It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is„ 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear, 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania ;  and  B.  Alex- 
ander Randall,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear 
in  the  University  of  Pennsylvania.  Imperial  octavo,  125 1  pages,, 
with  766  illustrations,  59  of  them  in  colors.  Cloth,  ;^7.oo  net; 
Half  Morocco,  ^8.50  net. 

Grtinwald  and  Grayson  on  the  Larynx 

Atlas  and   Epitome  of  Diseases  of  the  Larynx.     By  Dr.  L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology, 
University  of  Pennsylvania.  With  107  colored  figures  on  44 
plates,  25  text-cuts,  and  103  pages  of  text.  Cloth,  ^2.50  net. 
In  Saunders'  Hand-Atlas  Series. 


CHEMISTRY,   SKIN,  AND   VENEREAL   DISEASES.  is 

American  Pocket  Dictionary  sixth  Edition 

The  American  Pocket  Medical  Dictionary.    Edited  by  W.  A. 

Newman  Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 

of  the  University  of  Pennsylvania.     Containing  the  pronunciation 

and  definition  of  the  principal  words  used  in  medicine  and  kindred 

sciences.      598  pages.     Flexible   leather,  with   gold  edges,   ;^i.oo 

net;  with  thumb  index,  ^1.25  net. 

James  W.  Holland.  M.  D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 
Philadelphia, 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  ] 
can  recommend  it  to  our  students  without  reserve." 

Stelwa|(on*s  Essentials  of  Skin  7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  29 1  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  ^i.oo  net.  In 
Saimders'  Question- Comp end  Series. 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  liigh  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  New  (7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  ^^i.oo  net.  In 
Saunders'  Question- Compend  Series. 

Martin's  Minor  Surgery,  Bandaging^,  and  the  Venereal 

Diseases  second  Edition.  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.  Post-octavo,  166 
pages,  with  78  illustrations.  Cloth,  ^i.oo  net.  In  Saunders* 
Question- Compend  Series. 


i6  URINE,  EYE,  EAR,  NOSE,  AND    THROAT. 


Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.  D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New- 
York.    i2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  ;^  1.25  net 

British  Medical  Journal 

"  The  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some   extensive   tables   drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  PolycHnic.  Post-octavo  of  261  pages,  82  illus- 
trations. Cloth,  ^i.oo  net.  In  Saunders'  Question- Covipe'nd  Series. 
Johns  Hopkins  Hospital  Bulletin 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason*s  Nose  and  Throat  Fourth  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  112 
illustrations.     Clqth,  $1.00  net.     In  Saunders'  Question  Compends, 

The  Lancet,  London 

"The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition,  Revised 

Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.  B., 
M.  D.,  CHnical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.  Post-octavo  volume  of  214  pages,  with  114  illustra- 
tions.    Cloth,  ;^ 1. 00  net.      In  Satinders'  Qnestion-Compend  Series. 

Bristol  Medico-Chirurgical  Journal 

"We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

Wilcox  on  Genito-Urinary  and  Venereal  Diseases 

The   New   (2d)   Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases 
and  Syphilology,  StarHng-Ohio  Medical  College,  Columbus.  1 2mo 
of  321  pages,  illustrated.     Cloth,  ^i. 00  net.     Saimders'  Compends. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo'of  126  pages,  illustrated.  Cloth,  $1.25  net. 

Edward  Jackson.   M.  D.,  University  of  Colorado. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsLstx) 

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Surgical  after-treatment 


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